Landolfo, Kevin

Purpose: Despite the 2022 American Heart Association/American College of Cardiology guidelines recommending cardiac rehabilitation (CR) after aortic dissection repair, both patient participation in CR and the associated clinical outcomes remain poorly understood. Methods: Adults (≥18 years of age) discharged alive following thoracic aortic dissection surgery across the Mayo Clinic Enterprise (January 2012 to November 2022), with follow-up until May 2024, were included (IRB #24-001141). Data were presented using summary statistics and logistic regression modeling. Results: A total of 186 patients were referred; 37% were female, and the median age was 64 (51, 73) years. Dissections were classified as type A (43%), type B (18%), or a combination, and 55% had residual dissection. Over half (53%) did not start CR, with older age (aOR = 0.97: 95% CI, 0.94 - 0.99; P = .003), family history of aortic dissections and/or aneurysms (aOR = 0.17: 95% CI, 0.04 - 0.54; P = .005), and tobacco use (aOR = 0.35: 95% CI, 0.13 - 0.91; P = .037) being associated with lower odds of enrollment. Of the 87 who enrolled, 34 did so at a Mayo Clinic facility. There were no complications, with no difference in adverse outcomes. Among those with evaluations at graduation from CR (n = 21), quality of life (Dartmouth index 16 [14, 19] vs 25 [22, 30]; P = .002) and 6-minute walk distance (488 [375, 531] vs 302 [235, 398] m; P = .001) improved. Conclusions: Following thoracic aortic dissection repair, CR significantly improved quality of life and functional capacity without adverse events. Further work is needed to improve enrollment and establish data-driven safety margins for exercise.

Background: Progressive heart failure cardiogenic shock (HFCS) often requires escalation to temporary or durable mechanical circulatory support (MCS) as a bridge to transplant (BTT). Following the 2018 UNOS allocation changes, our center revised its BTT strategy to optimize support and shorten wait times. At our institution, the Impella 5.5 with SmartAssist via the axillary approach was selectively used for patients who remained refractory to guideline-directed medical therapy, failed single-inotrope therapy, and were not considered suitable durable LVAD candidates by our multidisciplinary heart team. We compared transplant-related outcomes of BTT patients supported with Impella 5.5 versus durable LVAD. Methods: We performed a single-center retrospective review of all heart and heart/kidney transplant candidates at Mayo Clinic Florida from October 2018 to February 2021. INTERMACS profile, baseline characteristics, and perioperative data were collected at the time of device implantation and throughout the transplant hospitalization. Results: A total of 87 heart and 4 heart–kidney transplants were completed. Forty-five patients (49%) required MCS as BTT: 27 (60%) with a durable LVAD and 18 (40%) with an Impella 5.5. All eighteen patients with Impella 5.5 as BTT (100%) were transplanted compared to nineteen patients with durable LVAD (70%), p = 0.001. The median time from listing to transplant was substantially shorter with Impella (32 vs. 696 days, p < 0.001), and this difference persisted across INTERMACS profiles. UNOS status at transplant was more urgent for Impella than LVAD (p < 0.001). Transplant surgery following Impella support required shorter cardiopulmonary bypass time (181 vs. 219 min, p < 0.001) and resulted in lower postoperative vasoactive-inotropic requirements (7.9 vs. 13, p = 0.003). No patients in the Impella group died or were delisted while awaiting transplant, whereas 5 LVAD patients (26%) died or were removed due to LVAD complications (p < 0.001). Conclusions: Our data demonstrates that the use of the Impella 5.5 as BTT was associated with significantly shorter waitlist time, higher transplantation rates, reduced perioperative morbidity, and lower postoperative vasoactive support compared with durable LVAD as BTT. These benefits were achieved despite a higher severity of illness at transplantation in the Impella cohort.

Abstract Background Patients with end-stage heart failure and chronic kidney disease requiring dual-organ transplantation (DOT) face significant challenges in utilizing durable mechanical circulatory support due to the risks associated with renal replacement therapies (RRTs) and multi-organ failure. Given the limited options available for long-term support in this patient population, there remains a critical need for alternative strategies to optimize end-organ function and bridge patients safely to transplant. With prolonged waitlist times for DOT, we present our experience with the Impella 5.5 as temporary mechanical circulatory support, demonstrating its potential to provide hemodynamic stability and support as a bridge to transplantation (BTT) in this complex cohort. Methods A single-centre retrospective review was completed of all patients listed for single-organ transplantation or DOT between December 2019 and November 2022 at Mayo Clinic in Florida, supported by the Impella 5.5 intended as BTT. The focus of this analysis was patients requiring RRT or listed for heart/kidney transplantation. Data were extracted from the electronic health record at baseline and during their transplant episode of care after institutional review board approval as exempt status for retrospective data collection. Results A total of 41 patients were supported with Impella 5.5, intended as BTT. All patients underwent successful transplantation. We focus on the 10 patients with Impella support who underwent DOT. In the DOT group, the median age at transplantation was 63 years (59–66), with nine males and one female. The baseline median ejection fraction was 19% (15–22), with 50% Caucasian and 50% African American and an even split between ischaemic and non-ischaemic aetiology. Median body mass index was 30 kg/m2 (26–31), and 60% were in blood group O. The median time on the waitlist for DOT patients was 53 days (29–75). Perioperative management of DOT Impella patients demonstrated baseline haemodynamics of RA 11 mmHg (7–16), mean PA 36 mmHg (32–47), PCWP 29 mmHg (21–35), mixed venous saturation (SVO2%) 51 (46–61) and Fick CI 2.03 L/min/m2 (1.66–2.5). Post-Impella placement haemodynamics demonstrated significant improvements in RA pressure to 5 mmHg (4–8), P = 0.02, SVO2 to 70% (65–72), P = 0.002, and Fick CI to 5.5 (5.2–8), P = 0.03. The average duration of support was 44 days (range 10–94). The median glomerular filtration rate at baseline was 27 mmol/L (16–29). Twenty-four hour urine protein averaged 168 mg/24 h (range 87–328), with the 24 h creatinine clearance of 29 mg/24 h (range 24–35). Eight of the 10 patients required continuous or intermittent RRT before DOT. The median total duration of RRT (including Impella support) was 36 days (9–72). DOT recipients had a 1 year survival of 90%, with an average follow-up of 432 days. Conclusions Our findings demonstrate that prolonged use of the Impella 5.5 provides safe and effective haemodynamic support for patients with end-stage heart and kidney failure awaiting dual-organ transplantation. With a 1 year survival rate of 90%, our data suggest that Impella 5.5 can be a viable alternative to traditional support strategies, particularly in patients who are otherwise limited by RRTs. As dual-organ transplantation becomes more prevalent, the Impella 5.5 offers a promising bridge to transplant, improving both short-term and long-term outcomes in this complex patient population.

Background: Despite expert opinion recommending patient-tailored cardiac rehabilitation (CR) after acute aortic dissection, both patient participation in CR and the associated risk factor modification after CR following aortic dissection repair are poorly understood. Objectives: To describe the characteristics of patients referred to CR, as well as the enrollment rate and outcomes of those referred to CR following thoracic aortic dissection. Methods: We reviewed electronic health records of adults (≥18) discharged alive following thoracic aortic dissection surgery across the Mayo Clinic Enterprise (01/01/2020-11/15/2022) with follow-up to 05/15/2024 (IRB #24-001141). Data are presented using summary statistics. Results: During the study period, 85 patients were included (median [IQR] age: 65 [50-75] years; 40% female; Table 1 ). Across 84% (N=71) who were referred to CR at discharge, 55% (N=39) enrolled. In those patients referred versus not referred to CR, the prevalence of type A dissection (75% vs. 43%), end-organ involvement (27% vs. 0%), and underlying CAD (54% vs. 21%) were greater while current tobacco use (9% vs. 29%) was lower. Of those enrolled at Mayo Clinic (N=16), CR was started 35 (28-65) days following surgery. These patients completed 21 (13-30) CR sessions at an exercise intensity of 59% (50-65%) maximum predicted heart rate. CR was discontinued in 44% (N=7) due to non-cardiac reasons ( Table 2 ). Of the 9 patients who completed CR, general health status (Dartmouth index: 19 [17-21] vs. 26 [22-34]), depressive symptoms (PHQ-9: 1 [0-1] vs. 4 [1-4]), and exercise capacity (6MWT: 214 [196-244] vs. 384 [305-597] meters) improved ( Table 2 ). There were no reported complications or deaths, with stable aortic sizes reported at 18 months. Conclusions: CR improves functional capacity and well-being without complications in patients after thoracic aortic dissection surgery. Further investigation is needed to better assess CR efficacy and usage in this population.

For donation after circulatory death, procurement is performed after the heart has arrested. This technique has been employed and adopted by clinicians to overcome the shortage of available hearts for transplant. Warm ischemia time plays a pivotal role in the survival outcome of the heart recipients. We describe a fast and safe technique to flush the heart during recovery from circulatory death donors in order to shorten the warm ischemia time.

Background and aim of the study: Congenitally corrected transposition of the great arteries (cc-TGA) is a rare type of congenital heart disease and heart-lung transplant (HLTx) is the potential solution if the patient developed severe biventricular failure.. Aim of the study is to present a challenging case of cc-TGA with dextrocardia managed by HLTx. Methods: A 53-year-old male patient was presented to our institution with biventricular failure. The echocardiogram revealed cc-TGA, dextrocardia with situs solitus, atrioventricular discordance and ventriculoatrial discordance, severe systemic and sub-pulmonary atrioventricular valves regurgitation, and severe pulmonary hypertension. He underwent heart-lung transplant. Results: The patient was discharged on postoperative day 25 on room air with normal left ventricular ejection fraction. Conclusion: This case highlights the complexity of preoperative and intraoperative management of cc-TGA, and demonstrates the challenges which the surgeons and anesthesiologists may face during the procedure of HLTx.

Extracorporeal circulation (ECC) support using intraoperative extracorporeal membrane oxygenation (ECMO) during lung transplantation (LTx) is now a routine practice for many high volume centers. Circuits that are dedicated to ECMO alone can be expensive and do not allow full cardiopulmonary bypass (CPB) to be performed. We describe our technique of instituting venoarterial ECMO during LTx using a less-expensive hybrid circuit that facilitates easy and immediate conversion to full CPB if needed, without interruption of ECC.