Shapiro, Anna Bovill

Abstract Background: Amyloidosis is a complex disease with a multitude of sequalae, particularly with the variants that cause cardiac amyloidosis. There is minimal literature on the types of procedures these patients undergo and the associated postprocedural outcomes. This gap of knowledge makes it difficult for anesthesia providers to risk stratify amyloidosis patients. Methods: This is a single-center, retrospective chart review study performed at a tertiary care medical center that serves as a referral center for patients with amyloidosis. Patients with a known diagnosis of transthyretin (ATTR) or light chain (AL) amyloidosis who underwent procedures requiring anesthesia between January 1, 2018 and October 24, 2024 were included in the study. The primary outcome was 30-day all-cause mortality. Secondary outcomes included other postoperative complications and analysis of types of procedures requiring anesthesia. Results: During the study period, 160 patients underwent a total of 466 procedures requiring anesthesia. Overall, 30-day mortality rate for all encounters was 1.7% (2.7% AL vs 0.5% ATTR, OR 5.71). Endoscopy was the most common procedure, accounting for 26.6% of all procedures. At the patient level, several procedures were more common in ATTR patients including TEE/Cardioversions (21.7% vs 6.6%, p=0.008), electrophysiology (36.2% vs 9.9%, p<0.001), and neurosurgery (13.0% vs 3.3%, p=0.031). Conclusions: In conclusion, patients with amyloid variants that cause cardiac amyloidosis carry substantial postoperative risk when undergoing procedures, with a trend toward increased mortality in patients with AL compared to ATTR. Patients with ATTR are more likely to require neurosurgery and treatment of arrythmias than patients with AL. Additional studies are needed to determine specific diagnostic parameters to help optimize these patients in the future. Trial Registration : Not applicable. Not a clinical trial

Background: Heart transplantation is the definitive treatment of end-stage heart failure and is a complex process involving coordination in procurement, preservation, and transport of a donor organ to a recipient. There are different heart transport methods, including the traditional static methods of Cooler and Ryobi and advanced dynamic methods, including SherpaPak and the Organ Care System (OCS). The aim of the study is to compare the post-transplant outcome of these in patients bridged with Impella 5.5. Method: A retrospective study was conducted between 2020 and 2025 after IRB approval. Patient demographics and clinical data was extracted from the medical record. Cox proportional hazards regression model was applied to identify independent predictors of mortality across 30-day, 90-day, and 1-year intervals. Results: 123 patients were included in the analysis. Age, EF and Race were similar between all groups. The transport method was a significant predictor of 1-year mortality. Use of OCS (HR=0.022, p value <0.05) and SherpaPak (HR=0.066, p value <0.05) was associated with a significant decrease in mortality compared to traditional cooler use. Across 30-day, 90-day, and 1-year intervals, OCS showed the strongest survival benefit, while SherpaPak also demonstrated reduced mortality, but less significant compared to OCS. Conclusion: Transport method is a strong predictor of 1-year post-transplant mortality, with OCS showing the most pronounced effect in reducing the risk of 1-year mortality as well as mortality across 30-day and 90-day intervals. These findings support broader adoption of advanced transport systems in clinical practice to improve post-transplant outcomes.

Background: Renal dysfunction is a known prognostic factor in advanced heart failure and among patients receiving temporary mechanical circulatory support (tMCS). However, the predictive value of post-Impella creatinine in determining healthcare resource utilization in patients bridged to transplant with Impella 5.5 remains unclear. This study aimed to evaluate the association between post-Impella creatinine and key hospitalization metrics in this population. Methods: We performed a retrospective cohort study of patients who received Impella 5.5 as a bridge-to-transplant between January 2020 and January 2025. Serum creatinine was collected 72 hours after Impella placement. The primary outcome was device-to-discharge time. Secondary outcomes included transplant-to-discharge time, post-transplant ICU length of stay (LOS), and total LOS (admission-discharge). Univariate and multivariable linear regressions were used to examine the association between post-Impella creatinine and each outcome, adjusting for age, gender, BMI, and LVEF. Results: 133 patients were supported with the Impella 5.5 as BTT and were included (median age 58 years (51–65), 82.7% were male, and 71.4% presented with non-ischemic cardiomyopathy. The median BMI was 27.7 (24.3–32.3), LVEF 17% (15–22), and post-Impella creatinine 1.32 mg/dL (0.96–1.71). The median device-to-discharge time was 45 days (29-64), transplant-to-discharge time was 14 days (12–19), ICU LOS post-transplant was 6 days (4–8), and total LOS was 58 days (42–76). Higher post-Impella creatinine was significantly associated with longer device-to-discharge time (β = 6.67, p = 0.004), longer transplant-to-discharge duration (β = 3.42 p = 0.003), longer ICU LOS (β = 2.19, p = 0.007), and longer total LOS (β = 7.24, p = 0.002) on univariate analysis. Post-impella creatinine remained significantly associated with device-to-discharge time in the multivariate model after adjusting for confounders (β = 6.33, p = 0.006). Importantly, this suggests that patients with lower post-Impella creatinine levels may experience shorter hospitalizations and faster recovery trajectories following transplant. Conclusions: Post-Impella creatinine is a significant predictor of prolonged hospitalization in patients supported with Impella 5.5 as a bridge to transplant. These findings emphasize the prognostic importance of early renal function assessment and may guide risk stratification and resource planning in advanced heart failure care.

Background: Mechanical support strategies used for patients in shock prior to heart transplantation (OHT) correlates with post-transplant outcomes. OHT timing in patients supported by Impella 5.5 remains an evolving decision point, influenced by patient stability and donor logistics. With the emergence of organ transport technologies, we sought to determine whether the choice of system was associated with variations in pre-transplant support duration. Method: A retrospective review between Jan 2020 and May 2025 was completed. Patients were categorized by donor transport technology: traditional cooler, Organ Care System (OCS), or SherpaPak. The primary outcome was duration of Impella support (days) prior to transplant. Group-wise comparisons were performed using Kruskal-Wallis testing. Result: A total of 129 patients were assessed across three transport methods: traditional cooler:12, OCS: 35, SherpaPak: 84. Median age at transplant was 58 (51-65) years with EF of 17% (15-22). Cold ischemic time differed significantly across transport technologies (Kruskal-Wallis H = 77.4, p < 0.001) and was longest in OCS cases (417 min), compared to SherpaPak (236 min) and traditional cooler (234 min). The median duration of Impella support prior to OHT was 27 days for organs transported via traditional cooler, 25 days for those using OCS, and 28.5 days for SherpaPak with near-significant difference by transport method (H=5.77, p=0.056). There was no significant difference of rejection within the first year after OHT. Conclusion: Donor transport technology choice may serve as a surrogate for broader transplant logistics and selection strategies as evidenced by significant differences in ischemic time and near-significant trends in Impella support duration.

Introduction: Takotsubo cardiomyopathy (TCM), also known as stress cardiomyopathy or Broken Heart Syndrome, is a reversible, transient state of myocardial dyskinesis and apical ballooning. Infrequently, TCM may progress to severe life-threatening complications such as cardiogenic shock. Early mechanical circulatory support (MCS) is crucial to myocardial recovery in these cases. We present one of the first cases of TCM successfully treated with the advanced micro-axial minimally invasive Impella 5.5 with SmartAssist MCS device. Case Presentation: A female in her late 70s with a history of hypothyroidism, atrial fibrillation post-ablation, and cholelithiasis was referred to our facility for an elective cholecystectomy. Post-anesthesia induction with propofol 2.1 mg/kg (140 mg bolus), she became bradycardic and hypotensive, eventually leading to asystole, requiring CPR and termination of the procedure. Echocardiography revealed a left ventricular ejection fraction (LVEF) of 24% with mid-ventricular akinesis and apical ballooning with mild mitral regurgitation, suggesting the diagnosis of TCM. Cardiac catheterization showed RA 20 and mean PA 42 mmHg. Lactate was 18.7 mmol/L and LDH 1776 U/L, suggesting progressive shock. Continuous epinephrine 0.1 mcg/kg/min and norepinephrine 0.06 mcg/kg/min were titrated for BP 97/58, and she was initially supported with the Impella CP device. Despite aggressive efforts, rising LDH levels and increased vasopressor needs indicated inadequate organ perfusion, requiring an upgrade to Impella 5.5. Impella 5.5 support for 11 days led to impressive myocardial recovery, leading to reductions, and eventual discontinuation, of inotropes and vasopressors. Post-Impella 5.5 explantation, her LVEF was 59–65% and she was discharged with Mobile Cardiac Outpatient Telemetry (MCOT) monitoring for her arrhythmias and reinitiation of guideline-directed medical therapies (GDMTs) for her comorbidities. Her 2-month follow-up shows sustained LVEF greater than 45% with functional improvements. Conclusions: Early escalation within 24 h of Impella CP to Impella 5.5 provided stabilization of cardiometabolic shock, preventing end-organ damage, allowing recovery of native heart function while maintaining ambulatory status, and allowing for optimizing medical therapy. It presents a safe, minimally invasive, and cost-effective intervention in TCM cases refractory to GDMT or when additional time is needed for decision-making in cases presenting with CS.

The use of temporary mechanical circulatory support in refractory heart failure cardiogenic shock (HFCS) has risen, leading to potential complications. Post-Cardiac Injury Syndrome (PCIS) from Impella insertion is rare but may result from subclavian artery manipulation and aortic irritation. We report the first case of pericarditis (PCIS) caused by Impella 5.5 insertion in an HFCS patient awaiting heart transplantation. The patient developed chest pain, tachycardia, and hypotension post-Impella insertion. Laboratory results and electrocardiograms confirmed PCIS. Treatment with Ibuprofen and Colchicine was successful. He received a heart transplant 14 days later. This case emphasizes recognizing iatrogenic pericarditis after Impella insertion and the need to avoid additional myocardial strain.

Remimazolam is an ultrashort acting intravenous sedative-hypnotic approved for procedural sedation. We report a series of 8 cases of radiographically placed gastrostomy tubes using remimazolam as the sole anesthetic agent. Interventional radiology (IR) gastrostomy tube placement entails anesthetizing often complex patients in a nonoperating room environment. All 8 patients reported here underwent successful gastrostomy tube placement without the need for conversion to general anesthesia. Remimazolam is a feasible option to sedate patients for gastrostomy tube placement in the IR suite.