Device-related adverse events (DRAEs) are common with intra-aortic balloon pump (IABP) and microaxial flow pump (mAFP) in cardiogenic shock (CS), yet predictors of DRAEs are underrecognized. We performed a single-center, retrospective review of consecutive adults from 8/2021 to 8/2024 with CS and IABP or mAFP. Events were adjudicated as device-related if occurring during IABP/mAFP support or <72 hours of removal. DRAEs included bleeding, bacteremia, stroke/transient ischemic attack, vascular injury, heparin-induced thrombocytopenia, and major hemolysis. Multivariable regression was performed to identify independent predictors of DRAEs. The study population (n = 400) was predominantly male (71.5%) with stage D/E CS (53.7%). In total, 251 DRAEs were identified. Independent DRAE predictors included non-white race, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) exposure, outside hospital device placement, and >1 device, while IABP-only was protective. Among those with mAFP, VA-ECMO exposure, outside hospital device placement, and >1 device were independent DRAE predictors. Further investigation into DRAE prevention strategies is warranted.
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.
暂无摘要（点击查看详情）
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.
Bronchiolitis obliterans syndrome (BOS), the most common form of chronic lung allograft dysfunction after lung transplantation, is characterized by progressive small airway disease (SAD) and is associated with poor outcomes and limited therapeutic options. Sotatercept, an activin-signaling inhibitor approved for pulmonary arterial hypertension, has been associated with improvements in physiologic markers of SAD in patients with pulmonary hypertension. In this report, we describe a 55-year-old woman with primary ciliary dyskinesia status post bilateral lung transplantation who developed stage 3 BOS complicated by hypercapnic respiratory failure requiring mechanical ventilation. Following initiation of off-label sotatercept, she experienced rapid clinical and radiologic improvement, permitting transient liberation from mechanical ventilation before succumbing to progressive respiratory failure. Further study is required to assess the potential role for activin pathway modulation in advanced BOS.
Left ventricular assist device (LVAD) driveline infections (DLIs) are common complications (1) and frequently recur despite definite treatment due to bacterial entry and biofilm formation. We report the first case of recurrent, extensively drug-resistant Pseudomonas aeruginosa LVAD infection successfully cured using systemic antimicrobials, continuous in-situ targeted antibiotics (CITA), and repeated surgical interventions, highlighting CITA's therapeutic potential.
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.
Ex vivo lung perfusion (EVLP) is a well-established method for assessing and reconditioning donor lungs before lung transplantation (LTx). Remarkably, clinical outcomes between standard criteria and marginal donor lungs after EVLP are similar despite differences in lung quality. Therefore, we explored several biomarkers during EVLP in this study. Novel findings could guide future interventions to enhance lung quality and expand the donor pool. EVLP was performed for ≥180 min with 18 standard criteria (logistical) and 15 marginal donor lungs. The biomarkers were measured in the perfusate after 90 and 180 min: d-dimer, Prothrombin Fragment 1+2 (F1+2), Plasminogen Activator Inhibitor-1 (PAI-1), urokinase Plasminogen Activator Receptor (uPAR), IL-1β, IL-6, IL-8, TNF-α, syndecan-1, hyaluronan and Vascular Cell Adhesion Molecule-1 (VCAM-1). In the logistical and marginal group, 16/18 and 12/15 were transplanted, respectively. All biomarkers increased significantly during EVLP. Remarkably, d-dimer, F1+2, uPAR, IL-6, IL-8, syndecan-1, hyaluronan, and VCAM-1 were significantly higher in the marginal group. Declined donor lungs had significantly higher levels of syndecan-1 and hyaluronan than all transplanted donor lungs. Lung function during EVLP and primary graft dysfunction (PGD) were similar between the transplanted standard and marginal lungs. No significant correlations with PGD were observed. Marginal donor lungs sustained more injury as reflected in higher levels of fibrin degradation, inflammation, glycocalyx shedding, and endothelial activation. In addition, declined donor lungs exhibited significantly higher glycocalyx shedding. Therefore, both logistical and marginal donor lungs could potentially benefit from thrombolysis, inflammation-reducing therapy, and endothelial preservation during EVLP to enhance lung quality.
Shortage of donor lungs for transplantation is largely a consequence of low utilization rates and long waitlists persist despite growth of transplant activities. Low utilization frequently reflects early respiratory complications. We describe a brain-dead potential donor with lung infiltrates and relative hypoxemia, in whom lung suitability for transplantation was restored after airway clearance with mechanical insufflation-exsufflation (MI-E), combined with nebulized hypertonic saline (HS). To our knowledge, this is the first description of effective non-invasive recovery of donor lungs through active secretion mobilization. The low-cost uncomplicated combination of interventions warrants prospective evaluation for inclusion in donor-management protocols.
Elevated heart rate is associated with adverse outcomes in patients with heart failure. Heart transplant recipients often have elevated heart rate; however, the long-term associations of elevated heart rate with clinical outcomes are unknown. The records of all pediatric (≤21 years) heart transplant recipients at our institution were reviewed. Patients who died or lacked a clinic visit within 1 year following heart transplant were excluded, as were those with a permanent pacemaker. Heart rate was collected from outpatient electrocardiograms and converted to Z-scores using age-specific normative data. The cohort was divided into elevated and normal heart rate groups, with elevated heart rate defined as an average HR Z-score ≥95th percentile during the first post-transplant year. Outcomes, including survival, rejection, and cardiac allograft vasculopathy were compared between groups. A total of 110 pediatric heart transplants were included (median age 11.4 years; 62% male). Thirty-six (33%) had an elevated heart rate. The elevated heart rate group was older (15.8 vs 6.1 years, p<0.001) and had shorter follow-up (3.0 vs 4.7 years, p = 0.007). Elevated heart rate was independently associated with increased risk of death (HR 5.44, 95% CI 1.47-20.2, p = 0.011) and a composite of death or rejection (HR 3.06, 95% CI 1.30-7.20, p = 0.010), but not cardiac allograft vasculopathy. Among patients who survive the first year after pediatric heart transplantation, elevated heart rate during the first post-transplant year is independently associated with increased risk of mortality and rejection. Further work is necessary to determine whether pharmacologic modulation mitigates this risk.
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.
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.
Double lung transplantation (DLTx) generally provides better survival than single lung transplantation (SLTx). However, SLTx recipients may often be more deconditioned, making direct comparisons challenging. The objective of this study is to investigate the transplant outcomes in patients waitlisted for both SLTx and DLTx to minimize differences in recipient background. The United Network for Organ Sharing Database was retrospectively analyzed. The patients who were waitlisted from December 2017 to February 2023, then removed from the waiting list in the same time periods, were included in the analysis. Pediatric lung transplantation, multiorgan transplantation, and lung retransplantation were excluded. Of 4056 patients who were waitlisted for both SLTx and DLTx, 2127 patients (52.4%) received DLTx, 1351 patients (33.3%) received SLTx, and 578 patients (14.3%) were removed from waiting list without receiving lung transplantation. Median days on the waitlist were 36 days (IQR 12-93) for DLTx and 43 days (IQR 15-120) for SLTx. The lung allocation score at the time of transplantation was higher in DLTx group (50.58 ± 19.02 vs 44.67 ± 14.80, p < 0.001). DLTx recipients had significantly higher rates of prolonged intubation at 72 hours after transplantation (33.9% vs 19.9%, p < 0.001) and reintubation (19.3% vs 13.0%, p < 0.001). Median post-transplant length of hospital stay was longer in DLTx group (19 [IQR 14-33] vs 15 days [IQR 11-24], p < 0.001). However, DLTx group had significantly lower mortality than SLTx group (n = 3478, log-rank test p < 0.001). Among patients waitlisted for both DLTx and SLTx, DLTx recipients had lower post-transplant mortality, despite a more complicated immediate postoperative course compared to SLTx.
Surveillance bronchoscopy for lung transplant monitoring is a standard of care at most high-volume transplant centers, though methods vary based on institutional preferences. At our medical center, we perform bilateral bronchoalveolar lavage (BAL) and unilateral transbronchial biopsy. This study aims to determine how often bilateral BALs lead to a change in medical management. This is a single-center, retrospective cohort study enrolling 237 patients who underwent either bilateral or single lung transplant and who underwent 759 surveillance bronchoscopies with bilateral BALs from 2020 to 2025. Data collected included demographic data, cultured pathogens bilaterally, and pathology from unilateral biopsies. Different pathogens (DP) were defined by having two positive contralateral results with differing infectious agents, or a positive result in one lung with a negative result in the contralateral lung. Change in management was defined as either alteration of antibiotic coverage or immunosuppressive drugs. Eighty-three bilateral BALs (10.9%) identified DP. Of these, 43 discordant findings (5.7% of all procedures) resulted in a change in management. All 43 of these changes involved initiation or adjustment of antimicrobial therapy, and 3 (7.0%) involved an adjustment in immunosuppression. Common pathogens that prompted management changes were Pseudomonas aeruginosa (14/43 32.6%) and Aspergillus species (12/43 27.9%). Bilateral BALs identifies clinically significant DPs in over 1 in 10 surveillance procedures, with more than half of these findings directly altering patient care. Because the most common DP identified-P aeruginosa and Aspergillus species-are strongly associated with chronic lung allograft dysfunction, the results support the practice of performance of bilateral BAL for post-lung transplant surveillance.
Children supported with paracorporeal ventricular assist devices (VADs) are at increased risk of thrombotic complications despite anticoagulation advances. Bivalirudin, a direct thrombin inhibitor, has emerged as an alternative to heparin through initiatives led by ACTION. At our institution, a burst dosing protocol was implemented, consisting of a 20% to 50% dose increase per hour for 2 hours, to manage fibrin or pin-point thrombus deposition. In this case series, 9 patients received a total of 132 bivalirudin bursts across the duration of support. No bleeding events occurred within 12 hours of a burst, and no thromboembolic events occurred within 48 hours. These preliminary findings suggest that bivalirudin burst dosing is feasible and not temporally related to adverse events in our pediatric population requiring paracorporeal support. Further prospective investigation is necessary to validate safety, establish optimal dosing parameters, and develop standardized burst initiation criteria.
Pediatric lung transplantation is a life-saving procedure for children with end-stage lung disease. As immunosuppression and treatment have improved, so too have survival outcomes; however, pediatric lung transplant recipients still face challenges, including acute rejection, infection, and long-term issues such as chronic lung allograft dysfunction (CLAD). This review details early complications following pediatric lung transplantation and provides an explorative investigation of the mechanisms underlying acute allograft dysfunction, and current prevention and treatment strategies. Focus is then given to CLAD with an overview of the subtypes of CLAD, review of recognized risk factors, challenges around diagnostics, current treatment strategies, and importantly future research goals to aid in the better identification and characterization of CLAD. As our understanding of acute and CLAD has evolved over time so have prevention and treatment strategies, including the assessment and treatment of risk factors such as infection and aspiration. The diagnosis of CLAD, however, remains extremely challenging with limited treatment options. Future research should focus on the prevention of CLAD.
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.
Right ventricular (RV) dysfunction remains a major contributor of morbidity and mortality after heart transplantation, and yet its perioperative assessment is both technically challenging and frequently inconsistent. Transesophageal echocardiography (TEE) provides for continuous evaluation of RV structure and function and is uniquely positioned to guide real-time clinical decision-making across the course of transplant care. This review presents a clinically focused, multiparametric framework for TEE-based RV assessment in the preoperative, intraoperative, and postoperative realm. Key quantitative measures including fractional area change, tricuspid annular plane systolic excursion (TAPSE), tricuspid annular systolic velocity (S'), 3-dimensional RV ejection fraction, and RV longitudinal strain provide complementary but incomplete assessments of RV performance. Reliance on any single parameter is insufficient, particularly in the transplanted heart, where altered geometry, loading conditions, and surgical factors significantly influence measurement accuracy. Integration of these indices with qualitative assessment is critical for accurate interpretation. TEE plays a critical role in defining preoperative RV function and pulmonary vascular burden, guiding intraoperative management, including de-airing and graft assessment, and enabling early detection of complications such as primary graft dysfunction and RV failure. A structured, multifaceted TEE evaluation may reduce diagnostic variability, enhance hemodynamic management, and improve transplant outcomes.
Exercise capacity, evaluated using cardiopulmonary exercise testing (CPET), is an important prognostic factor in ambulatory heart failure (HF) patients. However, interpreting the results of CPET in young, ambulatory HF patients who tend to be optimistic about their prognosis is complicated. This study aimed to assess the clinical impact of CPET parameters in predicting the prognosis of young, ambulatory HF patients. This single-center retrospective observational study targeted young (≤50 years) HF patients with reduced ejection fraction (left ventricular ejection fraction ≤40%) and peak oxygen uptake (VO2) ≥12 mL/kg/min. The primary endpoint was occurrence of major adverse cardiovascular events (MACE), such as death, admission for HF, and fatal arrhythmia, within 1 year after CPET. A total of 113 patients (median age, 43 [35-47] years) were enrolled: of these, 45 (39.8%) experienced MACE (death, n = 2; admission for HF, n = 35; fatal arrhythmia, n = 8). Multivariate Cox regression analysis demonstrated age, plasma brain natriuretic peptide level, serum creatinine level, and ventilatory efficiency (VE/VCO2 slope) were associated with the occurrence of MACE within 1 year after CPET. Receiver operating characteristic curve analysis revealed a VE/VCO2 slope of 31 was the optimal cutoff value for predicting prognosis. Nearly 40% of young (≤50 years) HF patients with moderately reduced exercise capacity (peak VO2 ≥12 mL/kg/min) experienced MACE within 1 year after CPET. Among these patients, those with a VE/VCO2 slope ≥31 may warrant earlier consideration for left ventricular assist devices or heart transplantation.