Solid organ transplantation is an effective treatment for patients with end-stage organ disease. The prevalence of cardiovascular diseases (CVD) has increased in recipients. CVD remains a leading ...cause of mortality among recipients with functioning grafts. The pathophysiology of CVD recipients is a complex interplay between preexisting risk factors, metabolic sequelae of immunosuppressive agents, infection, and rejection. Risk modification must be weighed against the risk of mortality owing to rejection or infection. Aggressive risk stratification and modification before and after transplantation and tailoring immunosuppressive regimens are essential to prevent complications and improve short-term and long-term mortality and graft survival.
Evaluation of left ventricular devices is becoming increasingly important as the implantation of these devices increases. Cardiac computed tomography angiography (CCTA) has many potential advantages ...compared with plain radiographs and echocardiography to troubleshoot these devices and potentially help guide therapy. Heart failure (HF) remains a deadly, progressive disease with substantive and increasing morbidity, mortality, cost, and prevalence. Use of left ventricular assist devices (LVAD) as treatment for refractory HF has been steadily rising during the last decade. Seventy-four LVAD recipients who met an indication for CCTA were referred for scanning at our center for a total of 94 studies. All recipients had received a Heart Mate II (Thoratec, Pleasanton, CA) LVAD at a previous time. All patients underwent gated CCTA on a 320 row multidetector scanner (Aquilion ONE, Toshiba Medical Systems, Irvine, California, USA). Images were then reconstructed and analysis was performed using multiple oblique views. All 94 studies had technically good images. In survival analysis, 43 of the 74 LVAD patients had normal CCTA findings while 31 had abnormal CCTA results. The 6, 12, and 18 months survival was 93%, 79%, and 77% in those with normal results and 71%, 61%, and 61%, respectively, in the abnormal CCTA findings. Overall survival was statistically significant in when comparing the two groups (p = 0.003). Cardiac computed tomography angiography may be used as an aid for risk stratification and a potential indicator of short- and long-term prognosis in LVAD patients.
Abstract only
Introduction:
Patients with left ventricular assist devices (LVAD) are at increased risk for SARS-CoV-2 (COVID-19) complications. There is paucity of literature on factors influencing ...outcomes of LVAD patients with COVID-19 infection.
Methods:
A single center retrospective chart review of LVAD patients diagnosed with COVID-19 between March 2020 and March 2023, was performed to define the clinical characteristics and outcomes in this cohort. Demographics, clinical, laboratory, and imaging variables were analyzed.
Results:
Of 130 LVAD patients, 34 (26.2%) developed COVID-19. The cohort comprised of 27 males (79.4%) with a median age of 63.5 years and BMI of 27.6 (Table 1). Twenty-one had non-ischemic cardiomyopathy (61.8%) with either Heartmate 2 or Heartmate 3 LVADs (38.2% each). Most patients reported NYHA class III (44.1%). The common comorbidities included hypertension (94.1%), hyperlipidemia (79.4%), atrial fibrillation (67.4%), and chronic kidney disease (61.8%). Twenty-eight (82.4%) patients were hospitalized and 2 (7.1%) required mechanical ventilation (Table 2). The average initial and peak INR were 2.39 and 3.26, respectively. No complications of pump hemolysis or thrombosis, or systemic embolisms were noted. Two deaths were reported: one passed away while in the hospital from COVID-19, and another 16 months later due to sequelae of post-COVID pulmonary fibrosis.
Conclusions:
This is the largest single center study analyzing outcomes of COVID-19 in LVAD patients to date. Our cohort experienced a lower mortality rate from COVID-19 infection compared to prior studies. Larger studies are needed to guide management strategies and analyze long-term outcomes.
Heart failure is a disease affecting 6.2 million adults in the United States, resulting in morbidity and mortality in the short and long terms. Although options such as mechanical circulatory support ...and transplantation are considered a solution when medical management is insufficient, heart transplantation (HTX) is regarded as the better option, with a lower incidence of multiorgan failure. A limiting step for HTX is the inadequate donor pool, so options like donation after circulatory death and xenotransplantation have emerged as alternatives. The cardiac anesthesiologist plays a pivotal role in the perioperative management of donors and recipients. A full understanding of the nature of the disease, pathophysiology, and perioperative management is paramount to the success of an HTX program. The authors include an index case to illustrate the multidisciplinary approach to the disease and the implications of managing these complex patients presenting to the operating room.
IMPORTANCE: Left ventricular assist devices (LVADs) enhance quality and duration of life in advanced heart failure. The burden of nonsurgical bleeding events is a leading morbidity. Aspirin as an ...antiplatelet agent is mandated along with vitamin K antagonists (VKAs) with continuous-flow LVADs without conclusive evidence of efficacy and safety. OBJECTIVE: To determine whether excluding aspirin as part of the antithrombotic regimen with a fully magnetically levitated LVAD is safe and decreases bleeding. DESIGN, SETTING, AND PARTICIPANTS: This international, randomized, double-blind, placebo-controlled study of aspirin (100 mg/d) vs placebo with VKA therapy in patients with advanced heart failure with an LVAD was conducted across 51 centers with expertise in treating patients with advanced heart failure across 9 countries. The randomized population included 628 patients with advanced heart failure implanted with a fully magnetically levitated LVAD (314 in the placebo group and 314 in the aspirin group), of whom 296 patients in the placebo group and 293 in the aspirin group were in the primary analysis population, which informed the primary end point analysis. The study enrolled patients from July 2020 to September 2022; median follow-up was 14 months. INTERVENTION: Patients were randomized in a 1:1 ratio to receive aspirin (100 mg/d) or placebo in addition to an antithrombotic regimen. MAIN OUTCOMES AND MEASURES: The composite primary end point, assessed for noninferiority (−10% margin) of placebo, was survival free of a major nonsurgical (>14 days after implant) hemocompatibility-related adverse events (including stroke, pump thrombosis, major bleeding, or arterial peripheral thromboembolism) at 12 months. The principal secondary end point was nonsurgical bleeding events. RESULTS: Of the 589 analyzed patients, 77% were men; one-third were Black and 61% were White. More patients were alive and free of hemocompatibility events at 12 months in the placebo group (68%) vs those taking aspirin (74%). Noninferiority of placebo was demonstrated (absolute between-group difference, 6.0% improvement in event-free survival with placebo lower 1-sided 97.5% CI, −1.6%; P < .001). Aspirin avoidance was associated with reduced nonsurgical bleeding events (relative risk, 0.66 95% confidence limit, 0.51-0.85; P = .002) with no increase in stroke or other thromboembolic events, a finding consistent among diverse subgroups of patient characteristics. CONCLUSIONS AND RELEVANCE: In patients with advanced heart failure treated with a fully magnetically levitated LVAD, avoidance of aspirin as part of an antithrombotic regimen, which includes VKA, is not inferior to a regimen containing aspirin, does not increase thromboembolism risk, and is associated with a reduction in bleeding events. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04069156
Solid organ transplant (SOT) recipients are at high risk for severe disease with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection. Emerging variants of concern have ...disproportionately affected this population. Data on severity and outcomes with the Omicron variant in SOT recipients are limited. Thus we conducted this single‐center, retrospective cohort study of SOT recipients diagnosed with SARS‐CoV‐2 infection from December 18, 2021 to January 18, 2022, when prevalence of the Omicron variant was more than 80%‐95% in the community. Univariate and multivariate logistic regression analysis was performed to identify risk factors for hospital admission. We identified 166 SOT patients: 112 (67.5%) kidney, 22 (13.3%) liver, 10 (6.0%) lung, seven (4.2%) heart, and 15 (9.0%) combined transplants. SARS‐CoV‐2 vaccine series was completed in 59 (35.5%) recipients. Ninety‐nine (59.6%) and 13 (7.8%) recipients received casirivimab/imdevimab and sotrovimab, respectively. Fifty‐three (32%) recipients required hospital admission, of which 19 (35.8%) required intensive care unit level of care. Median follow‐up was 50 (interquartile range, 25‐59) days, with mortality reported in six (3.6%) patients. Risk factors identified for hospital admission were African American race (p < .001, odds ratio OR 4.00, 95% confidence interval CI 1.84‐8.70), history of coronary artery disease (p = .031, OR 3.50, 95% CI 1.12‐10.87), and maintenance immunosuppression with corticosteroids (p = .048, OR 2.00, 95% CI 1.01‐4.00). In conclusion, contrary to that in the general population, we found a higher hospital admission rate in SOT recipients with omicron variant infection. Further studies to investigate the efficacy of newer treatments are necessary, even as outcomes continue to improve.
Graphical :
Abstract
Background
Patients with left ventricular assist devices (LVAD) infected with SARS-CoV-2 may be at increased risk of complications and mortality. The purpose of the study was to analyze the ...characteristics and outcomes of LVAD patients with SARS-CoV-2 infection at our center.
Methods
A retrospective review of LVAD patients diagnosed with COVID-19 via PCR between March 1st, 2020, and March 1st, 2023, was conducted. Patient demographics, clinical, laboratory, and imaging data were collected. We performed descriptive statistical analysis on the data obtained.
Results
During the study period, we were actively following 130 LVAD patients, 34 (26.2%) developed COVID-19. Our cohort consisted of 27 males (79.4%) with a median age of 63.5 years and median BMI of 27.6 (Table 1). Eighteen and 12 self-identified as African American (52.9%) and Hispanic (35.3%), respectively. The common comorbidities included hypertension (94.1%), hyperlipidemia (79.4%), atrial fibrillation (67.4%), and chronic kidney disease (61.8%). The most common presenting symptoms were shortness of breath (41.2%), cough (35.3%), and fever (29.4%). Nine (26.5%) patients were asymptomatic. Twenty-eight (82.4%) and 16 (57.1%) were admitted to the hospital and ICU, respectively (Table 2). Ten (35.7%) and 2 (7.1%) patients required supplemental oxygen via nasal canula, and mechanical ventilation, respectively. Most of the hospitalized patients were managed with Remdesivir (71.4%) and systemic corticosteroids (42.9%). No complications of pump hemolysis or thrombosis, or systemic embolisms were noted. Two deaths were reported: one patient (2.9%) died while in the hospital from COVID-19, and another patient died 16 months later secondary to acute respiratory failure in the setting of post-COVID pulmonary fibrosis.
Conclusion
This is the largest single center study analyzing outcomes of COVID-19 in LVAD patients to date. Our cohort experienced a lower mortality rate from COVID-19 infection compared to prior studies. Larger studies are needed to guide management strategies and determine optimal timing for heart transplant after COVID-19.
Disclosures
All Authors: No reported disclosures
