Barriers and opportunities in donation after circulatory death heart transplantation.

Background: Heart utilization from donation after circulatory death (DCD) donors remains highly variable across the United States, potentially resulting in missed transplantation opportunities. This study aimed to quantify the frequency of clinically viable, non-utilized DCD hearts and identify usage barriers.

Methods: We conducted a retrospective, national registry analysis of donors ≤55 years old who donated ≥1 organ, focusing primarily on DCDs.

Hypertension after solid-organ transplantation: special considerations for management.

Purpose Of Review: Hypertension is one of the most common comorbidities affecting patients after solid organ transplantation. Here we review the mechanisms leading to hypertension, along with common practices in terms of medical management. Glucagon-like peptide-1 receptor (GLP-1R) agonists, baroreflex therapy, and renal denervation are common interventions utilized prior to heart transplant.

Policy and Oversight of Cardiac Transplantation.

The first heart transplantation in the United States was performed in 1968. The first national heart allocation system was developed two decades later in 1988 as a two-tiered system. Our current heart allocation system, adopted in 2018 as a six-tiered system, is evolving to become a continuous distribution model.

Beyond GDMT: bridging the therapeutic gap in heart failure.

Guideline-directed medical therapy is the backbone of heart failure treatment. However, patients continue to experience heart failure symptoms, impaired quality of life, and reduced functional status despite guideline-directed medical and device treatment. There is a void in treatment alternatives between guideline-directed therapy and the advanced heart failure surgical options of heart transplant (HT) and left ventricular assist device (LVAD).

Spinal Cord Infarction as a Complication of VA-ECMO With Microaxial Flow Pump in Cardiogenic Shock.

Clinical Condition: The authors present the case of a young man who presented with cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation and microaxial flow pump complicated by acute spinal cord infarction (SCI) leading to bilateral lower extremity paraplegia.

Key Questions: The key questions included the following: 1) What is the incidence and pathophysiology for SCI with mechanical circulatory support (MCS)?; 2) Which configurations of MCS carry a greater risk of SCI? How do we approach MCS escalation, recognizing that with each device we carry additive risk of complications?; 3) What data guide anticoagulation strategies for MCS?; and 4) What strategies can we implement to support patients who have suffered SCI from MCS?

Outcome: Our patient was transitioned to a right ventricular assist device with Impella 5.5 as a bridge to therapy, and underwent cardiac transplantation 4 weeks after presentation with ongoing inpatient rehabilitation.

Tale of two assays: Comparison of modern donor-derived cell-free DNA technologies.

Little is known about the comparative differences between the Allosure (CareDx) and Prospera (Natera) donor-derived cell-free DNA (dd-cfDNA) assays following heart transplantation. We retrospectively analyzed 248 consecutive samples that had both dd-cfDNA assays simultaneously performed. Twenty-six biopsy specimens were available within 7 days from dd-cfDNA assays.

Outcomes of Donation After Circulatory Death Heart Transplantation Using Normothermic Regional Perfusion.

Background: Donation after circulatory death (DCD) with cardiopulmonary bypass for thoracoabdominal normothermic regional perfusion (TA-NRP) has led to increased use of donor hearts. Rejection rates and long-term survival outcomes are not known.

Methods: A single-center retrospective cohort review of patients who underwent DCD heart transplantation from January 2020 to December 2023 was performed.

Current approaches to optimize the donor heart for transplantation.

Heart transplantation remains a critical therapy for patients with end-stage heart failure, offering incremental survival and improved quality of life. One of the key components behind the success of heart transplantation is the condition and preservation of the donor's heart. In this review, we provide a comprehensive overview of ischemic reperfusion injury, risk factors associated with primary graft dysfunction, current use of various preservation solutions for organ procurement, and recent advancements in donor heart procurement technologies.

Heart Transplant Outcomes in Older Adults in the Modern Era of Transplant.

Background: Because of advances in medical treatment of heart failure, patients are living longer than in previous eras and may approach the need for advanced therapies, including heart transplantation, at older ages. This study assesses practices surrounding heart transplant in older adults (> 70 years) and examines short- and medium-term outcomes.

Methods And Results: This study is a retrospective analysis using the United Network for Organ Sharing (UNOS) database from 2010 to 2021.

Tailored Therapy in Cardiogenic Shock: Case-Based Management Choices.

Cardiogenic shock (CS) is a complex, multisystem disorder precipitated by hypoperfusion from cardiac dysfunction. Our current approach to defining and treating CS encompasses all patients under 1 umbrella regardless of phenotype. This has created challenges for clinical trials and patient care owing to the heterogeneity of the patient population with CS.

Baroreflex Function in Cardiovascular Disease.

The baroreflex system is involved in modulating several physiological functions of the cardiovascular system and can modulate cardiac output, blood pressure, and cardiac electrophysiology directly and indirectly. In addition, it is involved in regulating neurohormonal pathways involved in the cardiovascular function, such as the renin-angiotensin-aldosterone system and vasopressin release. Baroreflex dysfunction is characterized by sympathetic overactivation and parasympathetic withdrawal and is associated with several cardiovascular diseases, such as hypertension, heart failure, and coronary artery disease.

Sexual Quality of Life in Left Ventricular Assist Device Patients and Their Partners.

Background: Living with a left ventricular assist device (LVAD) comes with potentially burdensome aspects posed by, for example, battery packs and device drivelines. We aim to describe the impact of living with a durable LVAD on sexual quality of life (QOL), depression, and anxiety in patients and their partners.

Methods And Results: In this single-center, prospective, observational study, patients ≥4 months after LVAD implantation and their partners completed the Sexual Activities in Left Ventricular Assist Device Patients or Partners questionnaire to assess their sexual QOL, the 8-item Patient Health Questionnaire (PHQ-8) to assess symptoms of depression and the 7-item Generalized Anxiety Disorder (GAD-7) to assess symptoms of anxiety.

Bridge to Transplantation: Policies Impact Practices.

Since the development of the first heart allocation system in 1988 to the most recent heart allocation system in 2018, the road to heart transplantation has continued to evolve. Policies were shaped with advances in temporary and durable left ventricular assist devices as well as prioritization of patients based on degree of illness. Herein, we review the changes in the heart allocation system over the past several decades and the impact of practice patterns across the United States.

The impact of active cytomegalovirus infection on donor-derived cell-free DNA testing in heart transplant recipients.

Background: Little is known about the relationship between cytomegalovirus (CMV) infections and donor-derived cell-free DNA (dd-cfDNA) in heart transplant recipients.

Methods: In our study, CMV and dd-cfDNA results were prospectively collected on single-organ heart transplant recipients. If the CMV study was positive, a CMV study with dd-cfDNA was repeated 1-3 months later.

Does temporary mechanical circulatory support with Impella 5.5 induce de novo human leukocyte antigen antibodies production in heart transplantation candidates?

Background: Little is known about de novo human luekocyte antigen (HLA) antibody development with Impella 5.5 temporary mechanical circulatory assist support and downstream effects following heart transplantation in the new heart allocation system.

Methods: Thirteen Impella and 17 control patients without device support were prospectively enrolled between December 2020 and June 2022.

Three-year outcomes of de novo tacrolimus extended-release tablets (LCPT) compared to twice-daily tacrolimus in adult heart transplantation.

Background: Extended-release tacrolimus for prophylaxis of allograft rejection in heart transplant (HT) recipients is currently not FDA-approved. One such extended-release formulation of tacrolimus known as LCPT allows once-daily dosing and improves bioavailability compared to immediate-release (IR-) tacrolimus. We compared long-term efficacy and safety of LCPT to IR-tacrolimus applied de novo in adult OHT recipients.

Early elevated donor-derived cell-free DNA levels in heart transplant recipients following precision-controlled cardiac transport system or ice-cooled organ transport.

Background: Recent innovations in temperature-controlled cardiac transportation allow for static hypothermic preservation of transplant organs during transportation. We assessed differences in donor-derived cell-free DNA (dd-cfDNA) using the SherpaPak cardiac transport system (SCTS) and traditional ice transportation.

Methods: Single-organ heart transplant recipients between January 2020 and January 2022 were included if they had dd-cfDNA measures ≤6 weeks post-transplant along with the baseline biopsy at 6 weeks as part of the surveillance protocol and no biopsy-confirmed rejection ≤90 days.

Rejection! Or is it? Correlation among molecular microscope diagnostic system, histopathology and clinical judgement following heart transplantation.

Purpose: Little is known about clinical decision making among discordant findings concerning for rejection with endomyocardial biopsy (EMBx) and Molecular Microscope Diagnostic System (MMDx) in patients following heart transplantation.

Methods: Two hundred and twenty-eight corresponding EMBx and MMDx specimens from 135 adult heart transplant patients were retrospectively reviewed. Rejection was classified as t-cell mediated rejection ≥2R and/or antibody mediated rejection ≥1.