Right ventricular dysfunction in left ventricular assist device candidates: is it time to change our prospective?

The use of left ventricular assist devices (LVAD) has significantly increased in the last years, trying to offer a therapeutic alternative to heart transplantation, in light also to the significant heart donor shortage compared to the growing advanced heart failure population. Despite technological improvements in the devices, LVAD-related mortality is still fairly high, with right heart failure being one of the predominant predictors. Therefore, many efforts have been made toward a thorough right ventricular (RV) evaluation prior to LVAD implant, considering clinical, laboratory, echocardiographic, and invasive hemodynamic parameters. However, there is high heterogeneity regarding both which predictor is the strongest as well as the relative cut-off values, and a consensus has not been reached yet, increasing the risk of facing patients in which the distinction between good or poor RV function cannot be surely reached. In parallel, due to technological development and availability of mechanical circulatory support of the RV, LVADs are being considered even in patients with suboptimal RV function. The aim of our review is to analyze the current evidence regarding the role of RV function prior to LVAD and its evaluation, pointing out the extreme variability in parameters that are currently assessed and future prospective regarding new diagnostic tools. Finally, we attempt to gather the available information on the therapeutic strategies to use in the peri-operative phase, in order to reduce the incidence of RV failure, especially in patients in which the preoperative evaluation highlighted some conflicting results with regard to ventricular function.

New insights into the oncological risk in heart transplant recipients: could skin tumors represent a marker of increased risk for solid neoplasm?

BACKGROUND

Solid organ transplant recipients are at increased risk for skin cancers due to immune-suppressive therapies. However, little is known about the risk and the characteristics of neoplasms in heart transplant recipients (HTRs). The aim of this study is to delineate the incidence of different skin tumors in HTRs and to correlate it with the incidence of other malignancies, including solid tumors and hematological neoplasms.

METHODS

Patients who underwent to HTRs between January 1991 and November 2021 were retrieved. Clinical data on immunosuppressive therapies, skin tumors, solid and hematological neoplasms were obtained. HTRs with skin tumors were included in group A, while patients with no evidence of skin tumors during the follow-up were included in group B.

RESULTS

One hundred and eight patients were retrieved. A significant increase in solid tumors was observed in group A, while no significant difference in hematological neoplasms was detected between the two groups.

CONCLUSIONS

HTRs with skin tumors showed a significantly higher incidence of solid neoplasms. In most of the cases the skin tumor preceded the onset of the solid neoplasm, suggesting that the skin tumor could represent a 'marker' of immunosuppression eventually leading to the development of an internal malignancy.

Five-year recurrence after endoscopic approach to pilonidal sinus disease: A multicentre experience

PURPOSE

The aim of this study was to evaluate the 5-year recurrence rate of pilonidal sinus disease (PSD) after endoscopic sinusectomy and identify risk factors for recurrence.

METHODS

All consecutive patients from September 2011 through December 2017 who underwent endoscopic sinusectomy at seven referral centres for pilonidal sinus treatment were retrospectively analysed from a prospectively maintained database.

RESULTS

Out of 290 patients (185 males versus 105 female, with a mean age of 25.5±6.9), 73 presented recurrence at 5-year follow-up with a recurrence rate of 25.2%. The number of pilonidal sinus with pits off the midline (p = 0.001) and the mean (SD) distance from the most lateral orifice to the midline (p = 0.001) were higher in the group of patients with recurrence at 5-year follow-up. Multivariate analysis demonstrated that the position of the pits off the midline (p = 0.001) and the distance of the most lateral orifice from the midline (p = 0.001) were independent risk factors for recurrence at 5-year follow-up. Receiver operating characteristic (ROC) curve analysis showed that the distance of lateral orifice from midline predicted an 82.2% possibility of recurrence at 5-year follow-up and Youden's test identified the best cut-off as 2 cm for this variable. Out of 195 cases with the most lateral orifice less than 2 cm from the midline, 13 presented recurrence at 5-year follow-up with a recurrence rate of 6.7%. Out of 95 cases with the most lateral orifice more than 2 cm from midline, 60 showed recurrence at 5-year follow-up with a recurrence rate of 63.2%.

CONCLUSIONS

This data may help guide which disease characteristics predict the optimal use of an endoscopic pilonidal sinus technique.

Hydrogeological characteristics and water availability in the mountainous aquifer systems of Italian Central Alps: A regional scale approach

Groundwater resources in mountain areas are strategically important to maintain adequate water supply for domestic uses, farming, industrial activities, and energy production, also considering the expected growing demand due to ongoing climate changes. Within this framework, the objective of the study is to develop a regional approach, compliant with the European requirements of the Water Framework Directive 2000/60/EC and Groundwater Directive 2006/118/EC, that could support public agencies and water companies to efficiently manage and protect the available water resources in mountainous environments. The proposed approach identifies and delineates groundwater bodies by coupling a 3D hydro-stratigraphic model with the definition of the water budget and water hydrochemical fingerprints in a geologically complex Alpine environment in Northern Italy. Sixteen groundwater bodies (GWBs) have been identified all over the 10.290 km² area, showing an average storage capacity of more than 500 Mm³ y^-1 (about 3% of the average total inflow from precipitation and snowmelt), with differences up to four times between GWBs mainly constituted of carbonate rocks and those prevalently composed of crystalline or terrigenous rocks. Groundwater quality in the study domain is generally excellent, with few exceptions due to geogenic (i.e., natural) or anthropogenic sources of contamination. The results of this study show the advantages of coupling 3D hydro-stratigraphic modelling combined with meteorological, hydrological and hydrogeological information, which consist in: i) identifying the most Strategic Storage Reservoir both in terms of quality and storage capacity; ii) evaluating the present ground- and surface water availability; iii) detecting areas of specific interest for implementing groundwater monitoring networks; iv) recognising recharge areas of the most relevant springs, to implement protection strategies of the resource.

Inotropic therapy in patients with advanced heart failure. A clinical consensus statement from the Heart Failure Association of the European Society of Cardiology

This clinical consensus statement reviews the use of inotropic support in patients with advanced heart failure. The current guidelines only support use of inotropes in the setting of acute decompensated heart failure with evidence of organ malperfusion or shock. However, inotropic support may be reasonable in other patients with advanced heart failure without acute severe decompensation. The clinical evidence supporting use of inotropes in these situations is reviewed. Particularly, patients with persistent congestion, systemic hypoperfusion, or advanced heart failure with need for palliation, and specific situations relevant to implantation of left ventricular assist devices or heart transplantation are discussed. Traditional and novel drugs with inotropic effects are discussed and use of guideline-directed therapy during inotropic support is reviewed. Finally, home inotropic therapy is described, and palliative care and end-of-life aspects are reviewed in relation to management of ongoing inotropic support (including guidance for maintenance and weaning of chronic inotropic therapy support).

Donor heart selection: Evidence-based guidelines for providers

The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review.

1128 CLINICAL CHARACTERISTICS AND MANAGEMENT OF CARDIOGENIC SHOCK IN PATIENTS ELIGIBLE FOR CARDIAC TRANSPLANTATION AND LEFT VENTRICULAR ASSIST DEVICE

Aims

to describe epidemiology, clinical characteristics and treatment modalities adopted in a cohort of patients eligible for cardiac transplantation or left ventricular assist device implantation admitted for cardiogenic shock atour center. Secondly, to identify clinical risk factors for in-hospital mortality to evaluate the role of surgical treatment options (cardiac transplantation and L-VAD implant) as modifiers of prognosis in this patient population.

Methods

We retrospectively identified discharge charts containing ICD-9 codes of cardiogenic shock (785.51) and IABP implantation (37.61) at our center in the period 2016-2021. Patients were considered eligible in the age rage 18-70 years old, according to the upper age limit of cardiac transplant and LVAD program. Patients presenting with cardiogenic shock after cardiac surgery, cardiogenic shock secondary to acute pulmonary embolism and acute aortic syndrome or patients needing IABP placement as preventive support for high-risk percutaneous or surgical myocardial revascularization procedures were excluded.

Results

163 patients were included in the study (mean age 56 years, 80% male). In this cohort of patients, the most common etiologies were represented by coronary artery disease (64% of patients) and cardiomyopathy (26% of patients), mostly idiopathic dilated forms followed by hypertrophic cardiomyopathy and cardiac amyloidosis. The remaining 10% of patients were affected by other forms of cardiac disease (which included acute myocarditis and cancer therapy-related CV toxicity). Diabetes mellitus and hypertension were the most common CV risks factors. Acute coronary syndrome was the underlying cause in 45% patients presenting with cardiogenic shock, while 56% of CS cases were due to acute decompensated heart failure not in the setting of ACS. Most patients (80%) were supported with IABP alone, while 10% needed cardiocirculatory support with ECMO. Regarding outcome, in-hospital mortality for CS was 30% (48 patients), while 36 patients (22%) underwent surgical treatment of heart failure with cardiac transplantation (21 patients) or L-VAD implantation (15 patients). Predictors of in-hospital mortality at univariate analysis were older age, lower eGFR at the time of shock (p=0,0001), persistence of elevated blood lactates > 2 at CS presentation and at 24 hours (p=0,0001), and a failure to improve in renal impairment at 24 hours. Multivariate analysis identified lower eGFR and high lactates at 24 hours as independent risk factors for in-hospital mortality.

Conclusions

cardiogenic shock still remains a high-mortality condition. Mechanical circulatory support could provide stabilization and bridge to urgent cardiac transplantation and L-VAD implantation in order to improve prognosis. There is still need for diagnostic and therapeutic protocols standardized to improve the prognostic stratification and survival of patients with cardiogenic shock.

1119 INTRA-AORTIC BALLOON PUMP AS BRIDGE TO HEART REPLACEMENT THERAPY IN CARDIOGENIC SHOCK COMPLICATING CHRONIC HEART FAILURE

Background

Temporary mechanical circulatory support (MCS) could provide stabilization and improve prognosis in selected patients with cardiogenic shock (CS). Intra-aortic balloon pump (IABP) is a common percutaneous MCS device, characterized by wide availability, easy deployment and low complication rate. Despite its use in CS caused by acute myocardial infarction has been discouraged based on available evidence, recent data have renewed the interest in IABP as bridge to heart replacement therapy (HRT; heart transplantation or durable LVAD implant) in patients with cardiogenic shock complicating acutely decompensated chronic heart failure. We sought to review our experience with IABP support in this population eligible for HRT at a large-volume transplant center.

Methods

We retrospectively reviewed all adult patients (> 18 years old) who received IABP at our center between 2016 and 2021. We included patients with chronic heart failure with reduced ejection fraction (LVEF < 40% for at least 3 months) eligible for heart replacement therapy (i.e. < 70 years old). Primary endpoint was IABP success defined as weaning to discharge or successful bridge to HRT without need for MCS escalation. In addition, in-hospital mortality without HRT and MCS complications were assessed.

Results

Study population consisted of 49 patients with mean age of 54±9 years, 84% of whom were male. Etiology was non-ischemic dilated cardiomyopathy in 72% of patients and mean LVEF was 19±5%. 12 patients (24%) were already listed for heart transplantation. 26 patients (53%) developed cardiogenic shock during hospitalization for acutely decompensated heart failure, while the others presented CS upon admission. IABP success was achieved in 32 (65%) of patients, of whom 13 (39%) were bridged to heart transplantation, 6 (18%) to durable LVAD, while 13 (43%) were weaned from support and discharged. 11 patients (22%) died without MCS upgrade or HRT, including one death occurring 18 days after IABP weaning. 6 patients (12%) required escalation of mechanical circulatory support: 5 with extracorporeal membrane oxygenator (ECMO), 2 of whom were transplanted, and 1 with axillary-implanted Impella 5.0 as effective bridge to durable LVAD. In-hospital mortality without HRT was 28%. Median duration of IABP support was 8 days (0-107). 66% of patients were treated with at least one and 12% with two or more inotropes. Complications occurred in 4 (9%) patients in IABP group, including 3 cases of limb ischemia without sequelae and one fatal bleeding not related to insertion site. Ischemic and bleeding complications were found in 4 out of 5 ECMO-supported patients. Among demographic and laboratory characteristics assessed at baseline and after 24 hours from shock, persistence of increased lactates (>2 mmol/l) at 24 hours and number of inotropic drugs were independently associated with both IABP failure and mortality.

Conclusions

In patients with cardiogenic shock complicating chronic heart failure, IABP appears a safe and effective bridge strategy to heart replacement therapy with favorable outcomes and acceptable complication rates. Persistence of markers of hypoperfusion and increased need for cardioactive drugs are associated with worse outcomes and should trigger evaluation for MCS escalation. More studies are needed to fully characterize the role and timing of IABP support in this clinical scenario.

636 LOOKING AT THE BIGGER PICTURE: FROM ACUTE MYOCARDITIS TO THE DIAGNOSIS OF A MULTISYSTEMIC DISEASE

A 49-year-old man without cardiovascular risk factors, recently diagnosed of asthma and rino-sinusal polyposis, entered the Emergency Department for chest pain, shortness of breath and non-productive cough. The patient was in stable conditions. Laboratory exams showed eosinophilic leucocytosis (WBC 33.000/sqmm, 60% eosinophils) and a mild elevation of C-reactive protein (CRP 2,2 mg/dL). ECG showed a sinus rhythm with flat T-waves in the antero-lateral leads. Troponin values were high but not suggestive of acute myocardial damage (9900 - 9700 ng/L). Echocardiography showed normal biventricular volumes with moderately depressed left ventricular ejection fraction (40%), hypokinesia of the antero-lateral wall in the mid-apical segments and mild pericardial effusion.

During the hospital stay he developed progressive respiratory failure, and he was transferred to a tertiary center to perform an endomyocardial biopsy (EMB) in the suspicion of acute myocarditis. EMB showed multifocal interstitial and sub-endocardial inflammatory infiltrates (predominantly eosinophils) with foci of myocellular damage, small vessels wall inflammation with hypertrophy of the muscular tunica. The overall picture was consistent with diffuse moderate eosinophilic myocarditis with small vessels vasculitis. The right heart cath performed in the same procedure and during diuretic therapy showed a normal hemodynamic profile (RAP 5 mmHg, PCWP 13 mmHg, CI 3,7 L/min/sqm). The patient was treated with high dose steroids, first intravenously (methylprednisolone 125 mg/day for three days), then orally (prednisone 80 mg/day) in slow decalage until a maintenance dose of 12.5 mg daily.

The recent-onset of asthma with hyper-eosinophilia and rhino-sinus-bronchial syndrome in the light of the present cardiac condition was consistent with eosinophilic granulomatosis with polyangiitis (EGPA). Chest CT showed two areas of ground glass at the left superior and right superior lobes. Other potential haematological and infective causes of hyper eosinophilia and viral causes of myocarditis were ruled out.

After the treatment, his clinical conditions improved, ECG was completely normalized, left ventricular systolic function improved (LVEF 50%) and eosinophil count was significantly reduced (Eosinophils 830/sqmm, 8,9%), whereas CT showed resolution of the lung infiltrates.

One month after discharge, the patient was still asymptomatic. Cardiac MRI showed normal biventricular ejection fraction (LVEF 55%) with circumferential subendocardial fibrosis involving only the left ventricle. EMB showed a complete resolution of the inflammatory infiltrates and of the vasculitic aspects. Eosinophil count was elevated (5660/sqmm, 36%). Therefore, steroidal dose was raised to 50 mg/day. After rheumatologic evaluation, a steroidal sparing strategy with cyclophosphamide and anti-IL5 antibody Mepolizumab was adopted, with good laboratory response. Three months later, cardiac MRI showed no signs of active disease. No further EMB was scheduled.

Through the presentation of this unusual cause of acute myocarditis, we want to underscore the importance of an early referral to a tertiary level center of patients with suspected myocarditis and reduced systolic function and the usefulness of histology to guide medical therapy in specific forms of myocarditis that can lead to a potential complete recovery.

1121 USE OF IMPELLA 5.0 AS BRIDGE TO LVAD IN CARDIOGENIC SHOCK: REPORT OF TWO CASES

Background

Left ventricle assist devices (LVAD) are an option in end stage heart failure (HF) as bridge to or alterative to heart transplantation. Adequate compensation of patient is key to obtain a good outcome. We report two cases of Impella 5.0 bridge to LVAD in patients with cardiogenic shock (CS) in which intra-aortic balloon pump (IABP) failed to obtain hemodynamic stability.

Case series

A) A 60 years old man developed CS after anterior myocardial infarction treated with primary PCI of left main coronary artery. At presentation patient was hypotensive with signs of hypoperfusion and pulmonary congestion: systemic blood pressure (SBP) 80/60 mmHg despite inotropic drugs, blood lactates 4 mmol/l, urine output of last 6 hours 0,4 ml/kg/h (INTERMACS 2). Echocardiography showed severe left ventricle disfunction with LVEF 15%, severe mitral regurgitation (MR) and sPAP 45 mmHg. Therefore, IABP was implanted. Right heart catheterization (RHC) showed pulmonary hypertension and high filling pressure with reduced cardiac output and increased pulmonary vascular resistance (mPAP 39 mmHg, CPWP 28 mmHg, CO 3 l/min, PVR 3.7 uW, PAPi 2.8); X-ray chest showed persistence of pulmonary congestion. After 9 days on IABP, patient underwent Impella 5.0 implant through right axillary artery as bridge to durable LVAD. Pulmonary artery catheter (PAC) monitoring showed reduction of pulmonary hypertension with mPAP 35 mmHg and CPWP 17 mmHg and chest X-ray documented improvement of lung congestion. Bedside rehabilitation was started. Two weeks later patient underwent LVAD HM3 implantation as destination therapy. The patient was discharge home on post-operative day 55. B) After subacute myocardial infarction with three-vessels disease, a 53 y.o. man developed severe congestive HF with severe left ventricular disfunction and was referred to our institution for evaluation. RHC showed pulmonary hypertension with pre-capillary component not reversible after enoximone test, contraindicating heart transplantation. Therefore, patient was candidate to receive LVAD as bridge strategy. Echocardiography at admission showed dilated and hypokinetic left ventricle (EDV 200 ml, LVEF 17% severe MR, sPAP 60 mmHg) and dilated and hypokinetic RV. During hospitalization the patient experienced CS with SBP 62/45 mmHg, 6-hours urine output of 1,4 ml/kg/h and blood lactates 8.3 mmol/l (INTERMACS 1) so femoral IABP was implanted. RHC was repeated both without IABP support (mPAP 37 mmHg, PCWP 28 mmHg, CO 1.4 l/min, CI 0.9 l/min/m2) and with IABP support (mPAP 32 mmHg, PCWP 18 mmHg, CO 2.15 l/min, CI 1.4 l/min/m2). During the following stay he developed S. Aureus sepsis requiring prolonged antibiotic therapy. Expecting a long time before LVAD, axillary Impella 5.0 was implanted in order to unload the LV and allow early patient mobilization. Subsequent PAC monitoring showed improvement of pulmonary hypertension and cardiac index (mPAP 24 mmHg, PCWP 9 mmHg, CO 5.1 l/min with Impella flow 4.2 l/min, CI 3.2 l/min/m2). After 11 days, patient received LVAD HVAD with uneventful course and was discharged on post-operative day 22.

Conclusions

Impella 5.0 is a surgically implanted intravascular microaxial blood pump that delivers up to 5 l/min of blood from LV to aorta, leading to improved perfusion and more efficient LV unloading. In patients with CS this can help to obtain better decongestion, RV recovery, and favorable preconditioning before LVAD implant. Moreover, axillary access allows better patient mobilization preventing cachexia after long time hospitalization.

Prevention of Surgical Site Infections in Neonates and Children: Non-Pharmacological Measures of Prevention

A surgical site infection (SSI) is an infection that occurs in the incision created by an invasive surgical procedure. Although most infections are treatable with antibiotics, SSIs remain a significant cause of morbidity and mortality after surgery and have a significant economic impact on health systems. Preventive measures are essential to decrease the incidence of SSIs and antibiotic abuse, but data in the literature regarding risk factors for SSIs in the pediatric age group are scarce, and current guidelines for the prevention of the risk of developing SSIs are mainly focused on the adult population. This document describes the current knowledge on risk factors for SSIs in neonates and children undergoing surgery and has the purpose of providing guidance to health care professionals for the prevention of SSIs in this population. Our aim is to consider the possible non-pharmacological measures that can be adopted to prevent SSIs. To our knowledge, this is the first study to provide recommendations based on a careful review of the available scientific evidence for the non-pharmacological prevention of SSIs in neonates and children. The specific scenarios developed are intended to guide the healthcare professional in practice to ensure standardized management of the neonatal and pediatric patients, decrease the incidence of SSIs and reduce antibiotic abuse.

Indications, Complications, and Outcomes of Cardiac Surgery After Heart Transplantation: Results From the Cash Study

Background

Allograft pathologies, such as valvular, coronary artery, or aortic disease, may occur early and late after cardiac transplantation. Cardiac surgery after heart transplantation (CASH) may be an option to improve quality of life and allograft function and prolong survival. Experience with CASH, however, has been limited to single-center reports.

Methods

We performed a retrospective, multicenter study of heart transplant recipients with CASH between January 1984 and December 2020. In this study, 60 high-volume cardiac transplant centers were invited to participate.

Results

Data were available from 19 centers in North America (n = 7), South America (n = 1), and Europe (n = 11), with a total of 110 patients. A median of 3 (IQR 2–8.5) operations was reported by each center; five centers included ≥ 10 patients. Indications for CASH were valvular disease (n = 62), coronary artery disease (CAD) (n = 16), constrictive pericarditis (n = 17), aortic pathology (n = 13), and myxoma (n = 2). The median age at CASH was 57.7 (47.8–63.1) years, with a median time from transplant to CASH of 4.4 (1–9.6) years. Reoperation within the first year after transplantation was performed in 24.5%. In-hospital mortality was 9.1% (n = 10). 1-year survival was 86.2% and median follow-up was 8.2 (3.8–14.6) years. The most frequent perioperative complications were acute kidney injury and bleeding revision in 18 and 9.1%, respectively.

Conclusion

Cardiac surgery after heart transplantation has low in-hospital mortality and postoperative complications in carefully selected patients. The incidence and type of CASH vary between international centers. Risk factors for the worse outcome are higher European System for Cardiac Operative Risk Evaluation (EuroSCORE II) and postoperative renal failure.

Role of Quantitative Flow Ratio in Predicting Future Cardiac Allograft Vasculopathy in Heart Transplant Recipients

BACKGROUND

Coronary angiography is the gold standard for cardiac allograft vasculopathy (CAV) diagnosis, but it usually detects the disease at an advanced stage. We investigated the role of quantitative flow ratio (QFR), a noninvasive tool to identify potentially flow-limiting lesions, in predicting CAV development in heart transplant recipients.

METHODS

Consecutive heart transplant recipients with no evidence of angiographic CAV at baseline coronary angiography were retrospectively included between January 2010 and December 2015, and QFR computation was performed. The relationship between vessel QFR and the occurrence of angiographic vessel-related CAV (≥50% stenosis) was assessed.

RESULTS

One hundred forty-three patients were included and QFR computation was feasible in 241 vessels. The median value of QFR at baseline coronary angiography was 0.98 (interquartile range, 0.94-1.00). During a median follow-up of 6.0 years (interquartile range, 4.6-7.8 years), vessel-related CAV occurred in 25 (10.4%) vessels. Receiver-operating characteristic curve analysis identified a QFR best cutoff of ≤0.95 (area under the curve, 0.81 [95% CI, 0.71-0.90]; P<0.001). QFR≤0.95 was associated with an increased risk of vessel-related CAV (adjusted hazard ratio, 20.87 [95% CI, 5.35-81.43]; P<0.001). In an exploratory analysis, QFR≤0.95 in at least 2 vessels was associated with higher incidence of cardiovascular death or late graft dysfunction (71.4% in recipients with 2-3 vessels affected versus 5.1% in recipients with 0-1 vessels affected, P<0.001).

CONCLUSIONS

In a cohort of heart transplant recipients, QFR computation at baseline coronary angiography may be a safe and reliable tool to predict vessel-related CAV and clinical outcomes at long-term follow-up.

Cardiovascular implantable electronic device therapy in patients with left ventricular assist devices: insights from TRAViATA

BACKGROUND

There is conflicting observational data on the survival benefit cardiac implantable electronic devices (CIED) in patients with LVADs.

METHODS

Patients in whom an LVAD was implanted between January 2008 and April 2017 in the multinational Trans-Atlantic Registry on VAD and Transplant (TRAViATA) registry were separated into four groups based on the presence of CIED prior to LVAD implantation: none (n = 146), implantable cardiac defibrillator (ICD) (n = 239), cardiac resynchronization without defibrillator (CRT-P) (n = 28), and CRT with defibrillator (CRT-D) (n = 111).

RESULTS

A total of 524 patients (age 52 years ±12, 84.4% male) were followed for 354 (interquartile range: 166-701) days. After multivariable adjustment, there were no differences in survival across the groups. In comparison to no device, only CRT-D was associated with late right ventricular failure (RVF) (hazard ratio 2.85, 95% confidence interval [CI] 1.42-5.72, p = 0.003). There was no difference in risk of early RVF across the groups or risk of ICD shocks between those with ICD and CRT-D.

CONCLUSION

In a multinational registry of patients with LVADs, there were no differences in survival with respect to CIED subtype. However, patients with a pre-existing CRT-D had a higher likelihood of late RVF suggesting significant long-term morbidity in those with devices capable of LV‑lead pacing post LVAD implantation.

Telemedicine (TM) during SARS-CoV-2 Outbreak

Purpose

As Italy faced SARS-CoV-2 outbreak as first country outside China, and our hospital converted most of activities into the ones for COVID-19 patients (pts), we had to manage the need for continuing care of advanced heart failure (HF), heart transplant (HT) and LVAD pts. TM was a possible strategy, but its role in this very sick cohort is unknown.

Methods

During the lockdown (03-05/2020), we decided to make either a phone (PV) or an in presence (IV) visit, selecting for IV pts listed for HT, with LVAD, recently HT, scheduled for a biopsy within 6 months after HT or a RHC for listing eligibility. In PV, we assessed symptoms, blood pressure, drugs, and programmed a subsequent IV. All pts in IV group were triaged by phone for COVID-19 symptoms or contacts and if scheduled for RHC or biopsy received SARS-CoV-2 swab 48 h before the procedure. Study endpoints were: combined incidence at 6 months of MACE (HF hospitalization, CV death and need for anticipated IV) in HF/VAD group, and MACE, rejection and any cause- hospitalization in HT group.

Results

Among 448 pts (57±12y, 240 HT, 191 HF, 17 LVAD), 52% were managed by PV and a subsequent IV was scheduled after 3±2 months. Pts managed by PV were healthier: in HF-VAD group they were less frequently listed, had less Afib, LVAD (2/17) (p<0.01 all); post-capillary PH (pC-PH) was similarly distributed; in HT group there were less pts transplanted in the last 5 years (15% vs 52%, p<0.01) and numerically less with 2R rejection in the previous 6 months (8.3% vs 27.1%, p=0.13).The PV group had a lower incidence of the endpoints in both HF/VAD and HT cohorts (92.3±2.3% vs 70.3±4.4%; 97.0±1.7%vs82.5±4.1%, p<0.01). Overall, the predictors of the endpoints at multivariate analysis were pC-PH and PV (HR: 5.2 and 0.1, p<0.03 both) and a recent 2R rejection (HR: 3.6, p=0.05) in the HF/VAD and HT group respectively.There were no cases of COVID-19 in IV; 5 pts got infected at home in a context of infection prevalence of 6/1000 inhabitants in our region and of 40% of hospital beds dedicated to COVID-19 pts.

Conclusion

In this retrospective study, by reporting an organization set up in a emergency situation, we show that TM can be safely used to manage stable HF, LVAD and HT patients, whereas pC-PH and a recent rejection may identify those needing IV. These data suggest that the availability of devices for monitoring pulmonary pressures may improve safety of PV in HF pts and that TM could be useful not only in a pandemic outbreak but also subsequently.

Longest reported support (7.5 years) with postauricular type of Jarvik 2000 axial-flow left ventricular assist device

Mechanical circulatory supports with left ventricular assist devices (LVAD) are nowadays an established treatment in end-stage heart failure for those patients who are waiting for an organ donation or are unsuitable for transplantation. The duration of LVAD support is variable, depending on the device, the intention to treat and the issues occurring during treatment, which can change the purpose treatment or accelerate the transplantation. Moreover, length of reported supports in the literature is heterogenous. In here, we present the clinical and surgical case of the longest LVAD support reported in the literature, as a bridge to transplantation, with axial pump Jarvik 2000 (Jarvik Heart, Inc, New York, NY).

Multi-aquifer susceptibility analyses for supporting groundwater management in urban areas

In the densely urbanised Milan Metropolitan area (northern Italy), the long history of anthropogenic activities still exerts a significant pressure on groundwater resource. One of the most serious threats to the water quality of urban aquifers is attributed to diffuse contamination, which is caused by a series of unknown small sources (i.e., multiple point sources) distributed over large areas. In the study area and in many industrialised regions of the world, tetrachloroethylene [PCE], trichloroethylene [TCE] and hexavalent chromium [Cr(VI)] represent the common example of long-standing and persistent pollution in groundwater. In the Milan Metropolitan area, high levels of PCE + TCE and Cr(VI) were detected in the shallow aquifer as well as in the deep aquifer. To assess and map the shallow and deep aquifers susceptibility to PCE + TCE and Cr(VI) contamination at a regional scale, the Weights of Evidence modelling technique has been applied. This method has been used to objectively evaluate the spatial correlation between the high presence of these pollutants in each aquifer and hydrogeological and land use factors that can potentially influence the contamination. Moreover, the results allowed us to quantify on a large scale the effect that preferential flowpaths, due to both thickness variation in the aquitard and the areal density of multi aquifer wells, have in reducing the protection of the underlying deep aquifer. The end-products of the study constitute a key tool to be used by water-resource managers and decision-makers for the improvement of groundwater management and protection strategies.

PCE point source apportionment using a GIS-based statistical technique combined with stochastic modelling

To meet the continuous growth of urbanised areas with the ever-increasing demand for safe water supplies, the implementation of new scientifically based methodologies can represent a key support for preventing groundwater quality deterioration. In this study, a new combined approach based on the application of the Weights of Evidence and the Null-Space Monte Carlo particle back-tracking methods was set up to assess tetrachloroethylene (PCE) contamination due to Point Sources in the densely urbanised north-eastern sector of the Milano FUA (Functional Urban Area). This combined approach offers the advantage of further enhancing the power of each individual technique by integrating both the advective transport mechanism, neglected by the Weights of Evidence, and the influence of specific factors, such as the land use variation, not considered by the Null-Space Monte Carlo particle tracking. To accurately test and explore the performance of this new approach, the analysis was carried out based on the simulation of synthetic PCE plumes using a groundwater numerical model already implemented in a previous study. The Weights of Evidence method revealed that the areas characterised by a groundwater depth lower than 17 m, a groundwater velocity higher than 2.6 × 10^-6 m/s, a recharge higher than 0.26 m/y and a significant variation of the industrial activities extent are the most susceptible to groundwater pollution. The Null-Space Monte Carlo particle back-tracking has proved to be effective in delineating the potential source zones and contaminant travel path. The proposed approach can offer additional insights for the protection of groundwater resource. The end-product provides crucial information on the zones that require to be prioritised for investigations and can be easily understood by non-expert decision-makers constituting an advanced tool for enhancing groundwater protection strategies.

Prognostic value and usefulness of Pulmonary Artery Pulsatility index (PAPi) in evaluation of heart transplant candidates

Background

Heart transplantation (HTx) is considered the best available treatment for patients with end stage heart failure. Candidate evaluation with right heart catheterization (RHC) is fundamental in order to exclude pulmonary hypertension with irreversible high pulmonary vascular resistance (PVR), which is associated with elevated post-HTx mortality. PVR, rather than directly measured, is derived by cardiac output and pulmonary artery pressures, which are strictly dependent on right ventricular (RV) function. The pulmonary artery pulsatility index (PAPi) is a hemodynamic parameter integrating the information of RV function and of pulmonary circulation, which could be useful in pre-HTx evaluation.

Purpose

We designed this study to evaluate the potential predictive influence of pre-HTx PAPi on post-HTx survival and to assess whether this index could add useful information in the pre-HTx evaluation of patients with advanced heart failure.

Methods

Consecutive adult HTx recipient at two medium-large tranplant centers between 2000 and 2017 with available data on pre-HTx RHC were retrospectively included. PAPi was calculated as the ratio of pulmonary artery pulse pressure to right atrial pressure. PAPi values in the lowest quartile were defined as reduced (PAPi&lt;1.67). The primary endpoint was all-cause mortality at 1-year post-HTx. The association of reduced PAPi with the primary endpoint was evaluated. Cox regression was used to adjust for clinical and hemodynamic variables. Analyses stratified by PVR status (≥3 WU vs. &lt;3 WU) were also performed.

Results

Among 655 HTx recipients (female 20,8%, age 53±11 years), median pre-HTx PAPi was 3.0 (interquartile range 1.67–5.32). Patients in the lowest versus the remaining PAPi quartiles had significantly reduced 1-year survival (78.0% vs 87.2%, p=0.006), also after adjusting for age, estimated glomerular filtration rate, total bilirubin, high PVR and urgent transplantation (adj-hazard ratio: 0.64; 95% confidence interval 0.51–0.82). When stratifying patients by estimated PVR status, reduced PAPi was associated with worse 1-year survival among patients with normal PVR (78.3% vs. 88.3% p=0.011), but not in those with increased PVR (78.0% vs. 82.6%, p=0.36) (Figure 1).

Conclusions

Pre-HTx PAPi, integrating information of RV function and pulmonary circulation, provides incremental prognostic value over traditional clinical and hemodynamic parameters among HTx recipient. The prognostic value appears important among patients with normal estimated PVR, possibly due to an underestimation of PVR in patients with impaired RV function. The integration of PAPi in the pre-HTx evaluation may lead to better patient selection and post-HTx survival.

Figure 1. 1 year survival stratified by PVR status

Funding Acknowledgement

Type of funding source: None

Outcome of patients on heart transplant list treated with a continuous-flow left ventricular assist device: Insights from the TRans-Atlantic registry on VAd and TrAnsplant (TRAViATA)

BACKGROUND

Geographic variations in management and outcomes of individuals supported by continuous-flow left ventricular assist devices (CF-LVAD) between the United States (US) and Europe (EU) is largely unknown.

METHODS

We created a retrospective, multinational registry of 524 patients who received a CF-LVAD (either HVAD or Heartmate II) between January 2008 and April 2017. Follow up spanned from date of CF-LVAD implant to post-HTx period with a median follow up of 44.8 months.

RESULTS

The cohort included 299 (57.1%) EU and 225 (42.9%) US patients. Although the US cohort was significantly older with a higher prevalence of comorbidities, survival was similar between the cohorts (US 63.1%, EU 68.4% at 5 years, unadjusted log-rank test p = 0.43).Multivariate analyses suggested that older age, higher body mass index, elevated creatinine, use of temporary mechanical circulatory support prior CF-LVAD, and implantation of HVAD were associated with increased mortality. Among CF-LVAD patients undergoing HTx, the median time on CF-LVAD support was shorter in the US, meanwhile US donors were younger. Finally, the pattern of adverse events (stroke, gastrointestinal bleedings, late right ventricular failure, and driveline infection) during support differed significantly between US and EU.

CONCLUSIONS

Although waitlisted patients in the US on CF-LVAD have higher risk comorbid conditions, the overall outcome is similar in US and EU. Geographic variations with regards to donor characteristics, duration of CF-LVAD support prior to transplant, and adverse events on support can explain the disparity in the utilization of mechanical bridge to transplant strategy between US and EU.

Postoperative outcomes following rehabilitation in patients with left ventricular assist devices

Postoperative rehabilitation is a cornerstone of the recovery pathway following left ventricular assist device implantation (LVAD), and patients are expected to conduct an autonomous life thanks to improved technology and increased knowledge of mechanical circulatory support. The primary purpose of the present study was to quantify clinical changes related to rehabilitation, in patients with LVAD: functional capacity, disability, and quality of life were identified as reliable outcomes to detect such changes. The current study was a scoping review conducted searching three primary databases, namely PubMed, Scopus, and Cochrane Library, from their inception until January 2020. After the selection process was completed, 12 citations were included in the present study. Three hundred eight three patients were included in the current analysis. Functional capacity, disability, and quality of life were investigated in 157, 215, 18 patients, respectively. Significant differences were found before and after rehabilitation. The mean walked distance at 6-Minute Walk Test improved from 319±96 to 412.8±86.2 metres (p<0.001), the mean score of the Functional Independence Measure from 68.4±11.8 to 92.5±10.8 points (p<0.001), the mean score of the Short Form-36 physical component from 32.7±29.9 to 55.5±24.7 points (p=0.009) and the mental component from 55.8±19.8 to 75.4±21.4 points (p=0.002). Postoperative rehabilitation is effective at improving functional capacity, disability, and quality of life in patients with left ventricular assist device; all these three domains are particularly expressive of the entity of patients' functional recovery.

Predicting hemorrhagic transformation and its timing from maximum cerebral lesion diameter in nonlacunar ischemic strokes

OBJECTIVES

We performed this retrospective cohort study to establish which factors are mostly indicative of the appearance of hemorrhagic transformation (HT) and of its time course in a sample of nonlacunar ischemic strokes.

MATERIALS AND METHODS

In 402 patients with nonlacunar ischemic stroke (75.0 ± 12.7 years, 192 male), clinical, laboratory, and neuroimaging variables obtained during the first 3 days of hospitalization were compared between patients with and without HT at computer tomography scan.

RESULTS

HT was documented in 129 patients (32.1%), including 36 with parenchymal hematoma (PH), after a median time of 6 days (range 1-27). Many variables were univariately associated with HT, but only 5 of them were confirmed in Cox regression (Hazard Ratio, 95% Confidence Interval): maximum cerebral lesion diameter (CLD) in cm (1.12, 1.06-1.18; p = .0001), hemoglobin in g/dl (1.16, 1.06-1.27; p = .002), blood glucose in mmol/L (1.10, 1.03-1.18; p = .007), prior anticoagulant therapy (1.82, 1.10-3.03; p = .02), and edema with mass effect (1.72, 1.08-2.75; p = .02). Thus, the most significant predictor was CLD. The overall risk of HT was minimum for CLD < 2 cm (1.5%), intermediate for CLD ≥ 2 and < 5 cm (22%), and maximum for CLD ≥ 5 cm (58%). The residual probability of having HT decreased progressively over time, and a simple formula is proposed to predict, from CLD in cm, when the probability of HT falls below 10%.

CONCLUSIONS

The main determinant of HT was CLD, a simple quantitative parameter that could prove useful, in particular, in deciding the timing of anticoagulation in cardioembolic stroke patients.

Heart Transplant and Hepato-Renal Dysfunction: The Model of End-Stage Liver Disease Excluding International Normalized Ratio as a Predictor of Postoperative Outcomes

INTRODUCTION

Preoperative liver and renal dysfunction remain surgical risk factors for both postoperative morbidity and mortality. The Model of End-Stage Liver Disease Excluding INR (international normalized ratio), or MELD-XI, score calculation may help as a predictor in patients with advanced heart failure. We analyzed the impact of progressive elevated MELD-XI values among recipients of heart transplant at our institution.

METHODS

The data of a total of 425 consecutive adult patients who underwent heart transplantation, between January 2000 and August 2018, have been reviewed and divided into 3 cohorts according to preoperative MELD-XI calculations (MELD-XI < 11; MELD-XI 11-18; and MELD-XI > 18). Early and late outcomes have been analyzed.

RESULTS

Patients with a MELD-XI score > 18 had a more critical clinical condition preoperatively and had a higher risk of early mortality (hazard ratio [HR] 1.45 [1.11-1.67], P < .001). They showed high risk for postoperative dialysis (HR 2.8 [1.5-5.3], P < .001), rethoracothomy for bleeding (HR 2.1 [1.2-4.1], P = .001), prolonged time of mechanical ventilation, time of intensive care unit stay (HR 2.2 [1.3-3.8], P = .005), and graft failure requiring mechanical circulatory support (HR 1.9 [1.1-3.3], P = .003). After risk adjustment per MELD-XI cohort, ischemic dilated cardiomyopathy, redo operation, and cold ischemic time > 240 minutes resulted in being the strongest predictors of early mortality (P < .001). The 5-year and 10-year survival for MELD-XI > 18 cohort was 63% and 47% vs 72% and 59% in the control group (MELD-XI < 18) (log-rank, P < .001).

CONCLUSIONS

Patients with an elevated preoperative MELD-XI profile presented more comorbidities and significantly lower survival. This suggests the MELD-XI score may provide further insight into appropriate recipient and eventual donor selection. Renal insufficiency and congestive hepatopathy should be properly optimized before heart transplantation.

P6311Is the new PH classification useful to assess the need for heart transplantation? Looking for harder markers for hard patients

Background

Pulmonary hypertension (PH) is an important prognostic marker among patients (pts) with heart failure. Recent ESC guidelines have introduced the concept of diastolic transpulmonary gradient (DPG) to differentiate combined (CpC) and isolated (IpC) post-capillary PH. However, its validation in a setting of patients evaluated for heart transplantation (HT) has been poorly explored; moreover, it doesn't incorporate right ventricular (RV) function.

Purpose

To analyze the prognostic role of current classification of PH and its interplay with RV function and diuretic therapy in pts with advanced heart failure referred for HT.

Methods

We included all pts evaluated for HT in our Center (2002–16) undergoing to a right heart cath (RHC), collecting data at first evaluation. Patients were divided into three groups: no PH (mPAP<25 mmHg), IpC-PH (mean PAP >25 mmHg, PVR<3 WU), CpC-PH (mean PAP>25 mmHg, PVR ≥3 WU and/or DPG ≥7 mmHg). Pulmonary artery pulsatility index (PAPi) was analyzed as a marker of RV function; oral furosemide>125 mg/day (median value) or i.v. diuretics/dialysis were considered as high-dose diuretics (HDD). The study endpoint was the combined incidence of death or need for high urgent HT, expressed as 2-yrs survival rate.

Results

Among the overall cohort of 458 pts (53.1±10.9 yrs, 82,6% males, 40.3% CAD, 9.3% on IABP), 57.9% had PH: 30.8% IpC-PH, 27.1% CpC-PH. Only 8 pts (0.2%) had DPG≥7, one with PVR<3. The use of HDD differed significantly according to PH classes (44.6% vs 56.3% vs 68.3%, no PH vs IpC vs CpC-PH respectively, p<0.01) and was associated with a worse outcome (p<0.01). The incidence of the primary endpoint in the overall cohort was 74.1±2.5%. While pts with CpC-PH had the worst prognosis, DPG≥7 did not predict the primary endpoint. At multivariate analysis, PVR ≥3 WU (HR: 16.7), PAPi <3.8 (median value, HR: 4.1), HDD (HR: 5.6) were independent predictors of the primary endpoint, (p<0.04 for all) as well as need for IABP (HR: 19.0, p<0.01), even adjusting for clinical variables. Lower PAPi values carried an higher risk at 2 years both in IpC and CpC PH groups, thus allowing to better stratify the need for urgent HT (81.6±6.6% vs 78.6±5.7% vs 67.3±6.7% vs 49.1±7.9% respectively, p<0.001) (Fig.1).

Figure 1

Conclusion

Our results suggest that, even if current definition of type 2 PH predicts the need of urgent HT, the incorporation of DPG ≥7 is epidemiologically irrelevant and doesn't increase accuracy, whereas combining an indirect marker of RV function (PAPi) with PVR assessment, even correcting for diuretic therapy, could help to better stratify the need of a rare resource like HT in patients with advanced heart failure and pulmonary hypertension.