Anticoagulation is standard in patients with left ventricular assist devices (LVADs), but the optimal regimen remains uncertain. While warfarin has historically been utilized, the use of direct oral anticoagulants is increasing. Using the TriNetX Collaborative Research Network, we identified adult HeartMate 3 (HM3) LVAD recipients treated with apixaban (n = 174) or warfarin (n = 1782). Propensity-score matching balanced demographics, comorbidities, and laboratory values, yielding 171 patients per cohort. The mean age was 53.3 ± 16.9 years in the apixaban group and 54.2 ± 15.3 years in the warfarin group, with males comprising 75% and 72%, respectively. All-cause mortality (14% vs. 16%; HR 0.88, p = 0.65) and stroke (14% vs. 17%; HR 0.83, p = 0.50) did not differ significantly. Gastrointestinal bleeding was significantly lower with apixaban (12% vs. 25%; HR 0.51, p = 0.01). These observational analyses support apixaban as a feasible alternative anticoagulation strategy in HM3 LVAD recipients.
This special issue of the Journal of Heart Transplantation Open is dedicated to Pediatric Thoracic Transplantation. The authors will discuss subjects related to pediatric lung transplantation such as access to donor organs, allograft dysfunction and role of functional status in outcomes.
Heart-lung transplantation (HLTx) has become increasingly rare over the past decades. However, HLTx remains the only life-saving option for patients experiencing end-stage cardiopulmonary failure. In parallel, extracorporeal membrane oxygenation (ECMO) has emerged as an established bridging strategy to isolated heart or lung transplantation. The role of ECMO before HLTx remains poorly defined, with current evidence limited to small series and case reports. Bridging patients to HLTx is complex, as support must address both gas exchange and hemodynamic instability in a highly heterogeneous population. The choice and configuration of ECMO must therefore be personnalized, guided by the patient's underlying disease and the expected duration of support.
Kidney and liver transplantation have become standard of care for medically eligible people with HIV (PWH) with end-organ disease in the US, but data on heart transplantation (HT) in PWH remains limited. We used US national registry data 2014-2024 to identify 197 recipients with HIV (HIV R+) vs 34,213 without HIV (HIV R-) and used nonparametric tests of trend and Gini coefficients to quantify changes over time. Adjusted Cox regression, stratified by transplant centers, and modified Poisson regression were used to compare transplant outcomes in HIV R+ vs HIV R-. Annual HIV R+ HT increased from 0.3% in 2014 to 0.9% of HTs in 2024 (p<0.001). Center clustering decreased slightly over time: 14/135 HT centers performed 80% of HIV R+ HT in 2014-2019 (Gini 0.80) and 35/143 performed 80% in 2020-2024 (Gini 0.72). Compared to HIV R-, HIV R+ were younger, more often Black. Prior to 2020, 1-year patient survival was 85% HIV R+ vs 91% HIV R- (adjusted hazard ratio for mortality [aHR] 1.30, 95% CI: [0.84-2.01]), and 1-year rejection was 27% vs 20% (adjusted relative risk [aRR] 1.35 [0.86-2.14]). After 2020, 1-year patient survival was 90% HIV R+ vs 92% HIV R-, (aHR 1.05 [0.66-1.65]), and 1-year rejection was 15% vs 15% (aRR 1.04 [0.67-1.61]). The practice of HT in PWH has expanded over time, though it is still clustered, occurring at 72 limited number of programs. Patient survival and rejection among HIV R+ are comparable to HIV R-.
During Ex Vivo Lung Perfusion (EVLP), it is standard practice to incorporate a leukocyte filter to remove donor passenger leukocytes and attenuate their inflammatory effects. The widely used leukocyte filter, LeukoGuard 6, seems to be ineffective in reducing circulating leukocytes during EVLP. Therefore, we performed contemporary leukocyte filtration using BioR 02 plus leukocyte filters to reduce these leukocytes and investigate whether inflammation could be reduced. EVLP was performed for a minimum of 180 min with 15 bilateral donor lungs. Perfusate samples were taken from the in- and outlet of the leukocyte filter, which was subsequently clamped after 60 min. Contemporary parallel leukocyte filtration was performed in 9 EVLPs (intervention group) and in 6 EVLPs without (control group). After EVLP, 6/6 donor lungs were transplanted in the control group and 6/9 in the intervention group. Leukocytes increased significantly from 30 to 180 min in the standard group compared with the intervention group. During EVLP IL-1, IL-6, IL-8, TNF-α, neutrophil elastase, CD-14, syndecan-1, hyaluronan and VCAM-1, levels were not significantly different between the groups at 90 and 180 min. Post-transplant, primary graft dysfunction (PGD) and 1-month survival were similar. The intervention group showed significantly lower circulating donor passenger leukocytes. However, this did not lead to attenuated inflammatory cytokines, leukocyte activation, glycocalyx shedding or endothelial activation. Clinical outcomes were similar between groups. Further research is needed to determine the exact effect of these donor passenger leukocytes.
Extracorporeal membrane oxygenation (ECMO) has become an increasingly vital intervention for patients with severe cardiac and respiratory failure, significantly improving short-term survival rates. However, there is growing recognition of the importance of long-term outcomes, including health-related quality of life (HRQoL), functional recovery, and psychological well-being. This narrative review synthesizes clinical studies, systematic reviews, and cohort analyses from the past 20 years using PubMed and Google Scholar, focusing on adult ECMO survivors. Studies consistently demonstrate that although many survivors achieve functional independence, a significant proportion experience persistent limitation. Common long-term sequelae include reduced physical capacity, depression, anxiety, cognitive impairment, and challenges in social reintegration such as returning into employment. Outcomes vary by ECMO modality: Veno venous (VV) ECMO survivors typically report better HRQoL than those receiving Veno arterial (VA) ECMO, although depression appears more prevalent among VV ECMO survivors. Significant complications including neurological injury, limb ischemia, and bleeding remain major contributors to morbidity, particularly in VA ECMO cohorts. The differences reflect variation in underlying disease and complication burden between the 2 modalities. Rehabilitation strategies emphasizing early physiotherapy, structured discharge planning, and comprehensive long-term follow-up are associated with improved functional and psychosocial outcomes. Despite rising survival, existing literature reveals considerable heterogeneity, a lack of standardized outcome measures, and limited prospective multicenter data. Future research should focus on innovations in ECMO circuit design, safer anticoagulation protocols, and the development of standardized rehabilitation pathways. Incorporating long-term functional, psychological, and social outcomes into ECMO care paradigms, is essential to move beyond survival towards meaningful recovery, ultimately optimizing quality of life for ECMO survivors.
Impella 5.5 pumps are increasingly used in cardiogenic shock (CS) for extended hemodynamic support (>14 days). Rates of adverse events have not been well-characterized during longer durations of support. Therefore, we sought to define patient characteristics and adverse event rates in short versus extended duration of Impella 5.5 support (DOS). Baseline demographics, clinical characteristics, and serious adverse events defined as death or serious deterioration of health (Serious Adverse Event (SAE): hemolysis, stroke, renal failure, and vascular complications) were analyzed. SAE exposure adjusted event rates were compared between patients supported ≤14 days (short DOS cohort) and >14 days (extended DOS cohort). Among the 2262 patients enrolled across 31 sites in the LOQI (Long-Term Outcome and Quality Impella) registry, 443 patients were supported with the Impella 5.5. Compared to the extended duration cohort, the short duration cohort were older, had a greater proportion of women, and had a higher incidence of hypertension. Event adjusted exposure rate (EAER) was significantly lower in the extended versus short DOS cohort for cumulative SAEs, (EAER: 0.0776 vs. 0.0235 events/day; p<0.001) as well as each of the individual components: hemolysis (0.011 vs. 0.0029), stroke (0.0086 vs. 0.0024), renal failure (0.0177 vs. 0.005), vascular complications (0.0124 vs. 0.0053), and bleeding (0.0235 vs. 0.0061). In a real-world setting, extended use of Impella 5.5 for >14 days did not increase the rate of serious adverse events and was able to provide hemodynamic support to a heterogenous group of patients presenting with cardiogenic shock with stable device performance.
Neonates with enterovirus myocarditis may require extracorporeal membrane oxygenation (ECMO). The contemporary prognosis and risk factors for mortality of neonates with enterovirus myocarditis supported on ECMO is unknown. Retrospective cohort study of Extracorporeal Life Support Organization (ELSO) registry patients < 28 days old supported on V-A ECMO with enterovirus myocarditis. Primary outcome was survival to discharge. Secondary outcome was transplant-free survival to discharge. Demographic and ECMO-related variables were assessed as predictors of survival and transplant-free survival to discharge. 163 neonates from 2000 to 2023 required ECMO for enterovirus myocarditis. The indication for ECMO was cardiac in 136 (83.4%) and eCPR in 16 (9.8%). Median duration of ECMO was 9.3 days (IQR 5.9-15.7). Hospital survival was 50.4% overall; 64.6% in the 2018 to 2023 era. ECMO bridge to VAD resulted in hospital mortality in 80%. Transplant-free survival at discharge was 44.2%. Variables negatively associated with hospital survival in multivariable regression analysis were age ≤ 8 days (OR 0.10, 95% CI 0.04-0.28), ECMO duration > 15.7 days (OR 0.29, 95% CI 0.11-0.78), central cannulation (OR 0.24, 95% CI 0.07-0.84), hyperbilirubinaemia (OR 0.15, 95% CI 0.03-0.89) and cerebral infarction (OR 0.07, 95% CI 0.01-0.72). ECMO is an effective bridge to recovery in neonates with enterovirus myocarditis, with contemporary survival comparable to other neonatal indications for extracorporeal support. Risk factors including age ≤ 8 days and ECMO duration > 16 days define a high-risk cohort. Neonates bridged directly to VAD from ECMO have a dismal outcome. There is a critical need to improve outcomes in neonatal enterovirus myocarditis.
Lung transplantation (LTx) eligibility assessment may reveal lung lesions suspicious for malignancy. Histological evaluation of these lesions may provide clarity regarding their origin and prevent delays in transplant eligibility decisions. This single-center case series presents the outcomes of navigational bronchoscopy in patients undergoing evaluation for LTx. All patients evaluated for LTx between September 2023 and December 2025 with suspicious lung lesions amenable to navigational bronchoscopy with cone-beam CT and navigation software were included in this retrospective single-center study. Out of 173 patients evaluated for lung transplantation, twelve (7%) had suspicious lung lesions. Eight patients were considered eligible for navigational bronchoscopy. The median nodule size was 12 mm (range 6-24 mm), with Herder risk scores ranging from 13% to 84% probability of malignancy. Seven patients had COPD as the underlying disease, with a median FEV₁ of 23% and DLCO of 35%. One patient had chronic lung allograft dysfunction. In all cases, the nodules were successfully reached. No complications occurred related to bronchoscopy or general anesthesia. The median procedure time was 60 min, and the median hospital stay was 7 h. In 88% of cases, the pathological results had direct clinical consequences for transplant eligibility and subsequent management. This series demonstrates that navigational bronchoscopy is a safe and effective diagnostic tool for evaluating suspicious lung lesions in patients undergoing assessment for lung transplantation. It can safely accelerate transplant eligibility decision-making and reduce diagnostic uncertainty.
Cardiovascular disease is a leading cause of morbidity and mortality, according to the most recent reports from the World Health Organization. The development of increasingly effective pharmacological and interventional therapeutic approaches, the increasing average age of the population, and the increased incidence of metabolic disorders have led to a veritable pandemic in the chronicity of cardiovascular disease, particularly in the prevalence of patients with heart failure. Cardiac rehabilitation is a multidisciplinary care program that plays a key role in supporting heart failure patients, their caregivers, and the national healthcare system. However, until now, available clinical studies have almost exclusively investigated the role of exercise in stable patients, with inadequate management guidelines and supported by engagement methods that are not always consistent with patient clinical status. In some Italian rehabilitation centers, attempts have been made to develop a new model in clinical projects led by networks of professionals, in which rehabilitation management occurs early, compared with hospitalization in the acute setting. This new model also involves patients with potential clinical instability, but without the need for interventional procedures exclusive to the acute setting. From this perspective, the aim of the current project, which adopts a lean management approach, is to highlight the systemic waste and critical issues emerging from this new model.
Primary graft dysfunction (PGD) remains the leading cause of early morbidity and mortality after heart transplantation. Despite consensus definitions, clinicians still rely on subjective, indirect assessments of graft performance to determine when to initiate ECMO after transplant concludes risking delayed support initiation. No real-time, physiology-based marker currently guides early PGD recognition or standardizes ECMO decision-making across centers. To evaluate the utility of the cardiac power output index adjusted for vasoactive support (CPOI-VIS) as an early, dynamic, and clinically actionable physiologic marker of PGD, capable of predicting imminent ECMO requirement and short-term outcomes after heart transplantation. All adult heart transplant recipients at a single center (January 2020 to June 2025 [n = 547]) were retrospectively analyzed. Multiorgan recipients, congenital heart disease, and patients leaving the operating room on ECMO were excluded. CPOI-VIS was calculated hourly for the first 72 postoperative hours and censored at ECMO initiation. Dynamic 6-hour risk modeling, rolling ROC analyses, and unsupervised functional trajectory phenotyping was used to characterize CPOI-VIS behavior and its association with ECMO within 72 hours. The primary endpoint was ECMO initiation; secondary endpoints included 90-day mortality, renal replacement therapy, and ICU length of stay. Sixteen patients (2.9%) required ECMO within 72 hours. CPOI-VIS values diverged immediately between ECMO and non-ECMO groups (p < 0.001). For every 1-unit decrease in CPOI-VIS, the associated hazard of ECMO in the next 6 hours more than doubled (HR 2.23; 95% CI 1.66-2.99; C-index 0.96). Across 0 to 72 hours, discrimination remained consistently high (median AUC 0.98; IQR 0.96-0.99) with a stable predictive threshold (median 4.8; IQR 3.9-5.7). Among those crossing CPOI-VIS < 4.8 W/m2, early ECMO (<24 hours) was associated with markedly lower 90-day mortality compared with later initiation (0% vs 40%), with a >93% posterior probability of benefit. A "low CPOI-VIS" trajectory was strongly associated with ECMO, renal failure, prolonged ICU stay, and increased 90-day mortality. CPOI-VIS is a robust, physiology-based, real-time marker of early graft dysfunction after heart transplantation that reliably identifies patients at high risk for imminent hemodynamic collapse and may guide earlier ECMO initiation.
Early retransplantation following initial orthotopic heart transplantation (OHT) is a rare occurrence, with early evidence suggesting unfavorable clinical outcomes. In October 2018, the United Network for Organ Sharing (UNOS) implemented the current 6-tier heart allocation system, prioritizing critically ill patients on temporary mechanical support. The impact of this policy change on early retransplantation remains unclear. We performed a retrospective cohort study using the UNOS database to identify adult patients who underwent cardiac retransplantation within 30 days of their initial OHT between 2014 and 2023. Patients were stratified by the allocation era into two 5-year periods: prior (pre-October 2018) and current (post-October 2018) era. Clinical variables were compared at both the initial and retransplant timepoints. The primary outcome was 1-year survival following retransplantation. Fifty-nine patients met the inclusion criteria, 17 (28.8%) retransplanted in the prior era and 42 (71.2%) in the current era. There were significantly more early retransplanted patients in the current era (42 (0.27%) vs 17 (0.14%), p = 0.046). Patients in the current allocation era were significantly older (55.9 vs 40.8 years, p = 0.001), more frequently male (76.2% vs 35.3%, p = 0.008), and had a higher prevalence of diabetes (31.0% vs 5.9%, p = 0.048). The use of ECMO (p = 0.424), LVAD (p = 1.0), IABP (p =1.0), ventilatory support (p = 0.873), and inotropes (p = 0.116) at the time of retransplantation did not differ significantly between the prior and current eras. Overall, 1-year survival following retransplantation was 55.9%, with 64.7% survival in the prior era versus 52.4% in the current era (p = 0.46). Mean time to death after retransplantation was non-significantly longer in the current era (74.7 vs 38.7 days, p = 0.542). Early cardiac retransplantation is performed in patients with very high acuity and is associated with poor outcomes. Since the 2018 allocation policy change, early retransplantation has become increasingly common, but the outcomes remain very poor with approximately 50% of them not surviving to the first year. These findings highlight important ethical considerations regarding organ allocation and candidate selection when considering early retransplantation.
Ex-vivo lung perfusion (EVLP) has expanded donor lung utilization, with over 1000 cases performed at our center since 2008. A next-generation Toronto EVLP system (TorEx EVLP) was introduced in December 2022, enabling simplified circuit setup by loading an organ chamber into an all‑in‑one device, potentially facilitating EVLP use at less experienced centers. This study reports the initial experience with TorEx EVLP and compares outcomes with (1) first‑generation EVLP and (2) conventional lung transplantation without EVLP. In this single-center retrospective cohort study, 1067 EVLP procedures were performed from September 2008 to September 2024 (first-generation EVLP [G1], n=874; TorEx EVLP [G2], n=193). Post-transplant short- and long-term outcomes were compared among G1, G2, and contemporaneous direct transplants without EVLP (direct, n=1575). Of 1067 EVLP cases, 684 were accepted for transplant (utilization: G1 64.4%, G2 62.7%), and 700 transplants were performed (including 16 split singles). G1 and G2 had significantly higher DCD donor use (direct vs G1 vs G2: 17% vs 48% vs 60%, p<0.001) and lower donor P/F ratios (422 vs 368 vs 368 mmHg, p<0.001). Recipients in G1 and G2 were older than direct recipients (59 vs 61 vs 65 years, p<0.05). Post‑transplant outcomes were similar across groups, including PGD3 at 72 h (15% vs 16% vs 10%, p=0.21), extubation within 72 h (65% vs 64% vs 68%, p=0.67), overall survival, and CLAD‑free survival. Despite higher-risk donor use, outcomes with both first- and next-generation Toronto EVLP systems were comparable to direct transplantation.
Airway complications remain a major cause of morbidity and mortality after cardiothoracic transplantation. The reported incidence of airway ischemic complications continuously varies widely. We conducted an international multicenter survey to better understand the global adoption of the 2018 ISHLT airway grading consensus system and to identify key challenges across centers and areas for potential refinement.
Pulmonary arterial compliance is reduced in pulmonary arterial hypertension and may be a valuable prognostic marker; however, little is known about phenotypic factors or how compliance correlates with a range of outcomes. Our objective was to identify factors associated with compliance and evaluate relationships between compliance, cardiac morphology, exercise metrics, and mortality for individuals with pulmonary arterial hypertension and otherwise similar resistive afterload. We analyzed data from adult participants of the PVDOMICS cohort with World Symposium Group 1 pulmonary arterial hypertension. Compliance was derived by right heart catheterization measurement of stroke volume divided by pulmonary artery pulse pressure. Linear regression and Cox proportional hazards were used to estimate associations with outcomes in staged models. In the cohort study population of 328 participants, several factors were associated with worse pulmonary arterial compliance, including older age, shorter time since diagnosis, higher pulmonary arterial wedge pressure, and connective tissue disease-associated pulmonary arterial hypertension. These associations persisted among individuals with otherwise similar pulmonary vascular resistance. Compliance was also associated with cardiac magnetic resonance-derived right ventricular morphology and exercise tolerance. There was a protective association between compliance and death or transplant, particularly among those with a mean pulmonary artery pressure ≤40 mmHg (HR = 0.44 per 1 mL/mmHg better compliance [95% CI 0.24, 0.82], p = 0.009). Pulmonary arterial compliance is associated with several patient factors, right heart adaptation, exercise tolerance, and survival. Future studies are needed to investigate the role of compliance in the pathophysiology of connective tissue disease-associated pulmonary arterial hypertension, risk stratification, and endotypes of disease.
Constrictive pericarditis most commonly occurs after cardiac surgery and has been rarely reported following lung transplantation. Limited data and variable presentations make diagnosis challenging in this population. We retrospectively reviewed patients who underwent lung transplantation at Mayo Clinic from January 2000 through December 2022. Patients who developed constrictive pericarditis after transplantation were identified. Demographic, echocardiographic, hemodynamic, and surgical data were collected. Among 960 lung transplant recipients, 15 patients (1.6 percent) developed constrictive pericarditis, and 5 (0.5%) required pericardiectomy. Of these 5 patients, mean age at transplantation was 57.9 years, all male, with 4 having undergone bilateral and 1 single-lung transplantation. Constrictive pericarditis developed a median of 8.4 months after transplantation, with a range of 83 days to 5.9 years. All patients presented with dyspnea and pleural effusions; one had ascites. Chronic kidney disease stage 3 or 4 was present in 3 patients. Echocardiography demonstrated a dilated inferior vena cava in 80 percent, pericardial effusion in 60 percent, respirophasic septal shift in 60 percent, and hepatic vein expiratory diastolic flow reversal in 20 percent. Right heart catheterization showed elevated right atrial pressure, a square root sign in 4 patients, and ventricular interdependence in all. Two-year survival after pericardiectomy was 60 percent. Constrictive pericarditis is an uncommon but important complication after lung transplantation. Because symptoms are nonspecific and echocardiography may be limited, diagnosis requires a high index of suspicion and invasive hemodynamic confirmation.
Right ventricular-pulmonary arterial (RV-PA) coupling more sensitively captures RV dysfunction and may identify those at risk for late right heart failure (LRHF). Fourteen left ventricular assist device patients underwent prospective RV pressure-volume loop assessment and outcome adjudication. RV-PA coupling was indexed by the ratio of pressure-volume-derived RV end-systolic elastance (Ees) to pulmonary arterial elastance (Ea). Receiver operating curves compared the ability of Ees/Ea with standard hemodynamic metrics to discriminate LRHF outcomes. Freedom from LRHF or cardiovascular-related death was compared between those above and below the Ees/Ea value with optimal sensitivity and specificity for LRHF (Ees/Ea = 0.36). Ees/Ea best discriminated LRHF outcomes (AUC 0.92; p = 0.002) compared with PAPi, RA/PCWP, and RVSWI (AUC 0.65, 0.71, 0.50). Patients with an Ees/Ea ≤ 0.36 (n = 7) were more likely to develop LRHF by 3-year follow-up compared with an Ees/Ea >0.36 (log-rank p = 0.004). RV Ees/Ea may discriminate LRHF outcomes and characterize subclinical RV dysfunction that may precede LRHF.
Early detection of acute cellular rejection (ACR) is vital for improving long-term outcomes in lung transplant recipients (LTRs). Transbronchial biopsies are the gold standard for diagnosing ACR, but bronchoalveolar lavage (BAL) offers a less invasive alternative for early detection. This study examines the cytological and microbiological features of BAL, its correlation with ACR diagnosed via transbronchial cryobiopsy, and compares the effectiveness of pathology and hematology methods in analyzing BAL samples. Additionally, it assesses the value of mucosal biopsies for ACR detection. Transbronchial biopsies and corresponding BALs from January 2020 to March 2024 were analyzed retrospectively. ACR was diagnosed using cryobiopsy according to ISHLT histopathological criteria. Associations between BAL parameters and ACR were assessed using mixed-effects analysis. Among 240 procedures from 143 LTR, 17.9% were diagnosed with ACR. Microbiological findings and mucosal biopsy analyses were not associated with ACR. In contrast, the relative lymphocyte counts in BAL (median 3% [IQR 2-5%]) was significantly associated with ACR (OR 1.07 [95% CI 1.02-1.12], p=0.004). A significant correlation between lymphocyte proportion and ACR severity was observed (r=0.385, p<0.001). A threshold of 5.7% lymphocytes achieved an ROC AUC of 0.715 (95% CI 0.613-0.817), with a positive predictive value of 66.7% and a negative predictive value of 76.5%. BAL lymphocytosis could support the diagnostic process of ACR. While mucosal biopsies and microbiological testing did not aid in ACR detection, BAL cytology provided relevant accuracy, particularly when assessed microscopically. These findings support incorporating BAL lymphocyte analysis into routine surveillance strategies for early ACR.
Cardiogenic shock during pregnancy carries substantial maternal and fetal morbidity and mortality, and guidance on temporary mechanical circulatory support (tMCS) in this setting remains limited. A 36-year-old woman at 21 weeks' gestation presented with severe dilated cardiomyopathy (ejection fraction 20%, LVIDd 8.0 cm), cardiogenic shock (cardiac index 1.7 L/min/m²), and recurrent ventricular arrhythmias. She declined termination of pregnancy. An axillary Impella 5.5 was placed for hemodynamic stabilization with rapid improvement in cardiac output and filling pressures. Progressive ventricular arrhythmias at 23 weeks and 3 days necessitated urgent cesarean delivery; the neonate did not survive. The patient was supported with the Impella 5.5 for 66 days and underwent successful orthotopic heart transplantation. To our knowledge, this is one of the longest reported durations of Impella 5.5 support initiated during pregnancy and continued into the postpartum period. This case highlights important considerations that may inform individualized multidisciplinary decision-making on temporary mechanical circulatory support selection in pregnancy-associated cardiogenic shock.
The clinical impact of atrial fibrillation (AF) in patients undergoing left ventricular assist device (LVAD) implantation remains uncertain, particularly regarding whether the post-LVAD rhythm status carries prognostic value. We retrospectively reviewed consecutive LVAD recipients at our institution between 2008 and 2023. Patients were categorized as no AF, new-onset AF, resolved AF, or recurrent AF according to rhythm status before and after implantation. The primary endpoint was hospitalization for heart failure, and the secondary endpoints were all-cause death, stroke, and major bleeding. Left atrial (LA) reverse remodeling was quantified as the percent reduction in LA diameter. Among 115 patients (mean age 46 years; 69.6% male; 14.8% ischemic etiology), 44 (38.3%) had AF before implantation. Over a median follow-up of 50.8 months, 29 of 44 patients (65.9%) had no AF recurrence by 3 months after implantation (resolved AF group), whereas 15 had AF (recurrent AF group); among the 71 patients without pre-LVAD AF, three developed new-onset AF. Compared with the recurrent AF group, the resolved AF group had a significantly lower risk of heart failure hospitalization (hazard ratio, 0.25; 95% confidence interval, 0.07-0.86; P = 0.027). LA diameter decreased to a greater extent in the resolved AF group than in the recurrent AF group (LA reduction rate: 24.5% vs. 10.8%; P = 0.032). LVAD implantation was associated with LA reduction through reverse remodeling and led to AF resolution in a subset of patients. Patients with AF resolution experienced fewer heart failure events during LVAD support.