Sanghavi, Devang

Introduction/Background: Patients with heart failure and those waiting for a heart transplant often experience a significant decrease in their ability to perform daily activities and exercise, leading to a lower quality of life. Although exercise-based cardiac rehabilitation (EBCR) is a possible treatment option, its effectiveness has not been well measured, resulting in limited adoption. Research Questions/Hypothesis: Could physical rehabilitation before receiving a heart transplant improve functional status and better outcomes? Goals/Aims: Our objective is to evaluate the effect of pre-transplant physical therapy on the standardized improvement of AM-PAC scores, measured from the earliest pre-transplant assessment to the most recent pre-transplant evaluation. Our second objective is to assess the impact of the latest Pre-Transplant AM-PAC Score on the number of hospital-free days following transplantation. Methods: We conducted a retrospective study on 91 heart transplant patients who received Impella support from January 2019 to April 2023, approved by the Mayo Clinic Institutional Review Board. We collected data on demographics, AMPAC scores, and outcomes at three time points. Continuous variables were compared using the T-test or Mann-Whitney test, and categorical variables using the Chi-square or Fisher's exact test. We used a linear regression model to investigate the relationship between rehabilitation duration and AMPAC scores. Quantile regression was preferred due to the non-normal distribution of the outcome, hospital-free days. Results: We conducted a linear regression analysis and found a statistically significant association between increased hours spent in PT and greater improvement. After one hour of physical therapy, there was an average increase of 1.07 (95% CI 0.1, 2; p=0.03) in AMPAC scoore. We also compared the change in the AMPAC score with hospital-free days, and it was statistically significant in quantile regression analysis, indicating an increase of 0.28 (95% CI 0.2, 0.55; P=0.03) points in the AMPAC Score, corresponding to an additional hospital-free day. Conclusion: Increased hours spent in physical therapy show a significant positive association with greater improvement in standardized AM-PAC Mobility scores and hospital-free days. These findings encourage increasing uptake and support of cardiac rehabilitation programs.

Background: In the landscape of organ transplantation, heart transplantation stands as a life-saving procedure for patients with end-stage heart failure. Comprehensive analyses of transplant programs are imperative to optimize outcomes and understand the complexities. Hypothesis: This study hypothesizes that an increasing trend of heart transplant service and short-term mechanical circulatory support (STMCS) is the bridge to transplant; the UNOS (United Network for Organ Sharing) guideline positively impacts STMCS utilization. Even with the standard of care, there might be a disparity in receiving care in terms of gender and race. Goal/ Aims: By examining this center's collective experience, this research provides valuable insights into the evolving landscape of heart transplantation, ultimately contributing to advancements in patient care and transplant policy. Methods: This retrospective cohort study includes heart transplant patients in a single large transplant center. For statistical analysis, Cox regression, Mann-Whitney test, Kruskal Wallis, and Chi-Square test were used in IBM SPSS 25. Result: Trends: This retrospective study covering 2010 to 2022 comprehensively analyzed 1513 heart transplant patients. The cohort consisted of 1071 (70.78%) males and 442 (29.21%) females, 31.9% were bridged through STMCS. 76.7% of Caucasian and 16.1% were African American.The mean utilization of STMCS was 20.08% before the UNOS policy change, increasing to 53.81% after that (p < 0.001). Disparity Analysis: There was a statistically significant difference in STMCS utilization between white and black patients (p= 0.008) but no difference in between obese and non-obese cohorts (P=0.362).Wait time was similar among the genders (p=0.161) and different races (p=0.302). Survival Analysis: There is a significant survival discrepancy between patients bridged through MCS and those without STMCS(p< 0.001). However, yearly trend analysis showed an evolving survival trajectory favoring STMCS users. There are statistically significant survival differences among whites and blacks (P =0.008) but similar among the genders (p=0.589). Summary: The study reveals significant changes in the trend of transplants regarding STMCS utilization since the UNOS guideline. There are substantial differences in survival between STMCS vs. non-STMCS groups and among the races.There was a significant difference in STMCS utilization among the races.

Background: The new Global definition of ARDS recently introduced a subgroup known as non-intubated ARDS. This study aimed to assess the risk of progression from noninvasive oxygen support to intubation and ARDS severity based on the S pO 2 /F IO 2 among non-intubated subjects with ARDS. Methods: This retrospective study included subjects with COVID-19 admitted to 7 hospitals (5 in the United States and 2 in Argentina) from January 2020–January 2023. Subjects meeting the new non-intubated ARDS definition (high-flow nasal cannula [HFNC] with an S pO 2 /F IO 2 ≤315 [with S pO 2 ≤97%] or a P aO 2 /F IO 2 ≤300 mm Hg while receiving ≥30 L/min O 2 via HFNC) were included. The study evaluated the proportion of subjects who progressed to intubation, severity levels using the S pO 2 /F IO 2 cutoff proposed in the new ARDS definition, and mortality. Results: Nine hundred sixty-five non-intubated subjects with ARDS were included, of whom 27% ( n = 262) progressed to meet the Berlin criteria within a median of 3 d (interquartile range 2–6). The overall mortality was 23% (95% CI 20–26) ( n = 225), and among subjects who progressed to the Berlin criteria, it was 37% (95% CI 31–43) ( n = 98). Additionally, the worst S pO 2 /F IO 2 within 1 d of ARDS diagnosis was correlated with mortality, with mortality rates of 26% (95% CI 23–30) ( n = 177) for subjects with S pO 2 /F IO 2 ≤148, 17% (95% CI 12–23) ( n = 38) for those with S pO 2 /F IO 2 between 149–234, and 16% (95% CI 8–28) ( n = 10) for subjects maintaining an S pO 2 /F IO 2 higher than 235 ( P < .001). Conclusions: The non-intubated ARDS criteria encompassed a broader spectrum of subjects with lower in-hospital mortality compared to the Berlin criteria. The S pO 2 /F IO 2 and ARDS severity cutoff proposed in the new Global ARDS definition were valuable predictors of in-hospital mortality in these subjects.

Extracorporeal membrane oxygenation (ECMO) is often used in acute respiratory distress syndrome (ARDS) with refractory hypoxemia. There is limited literature highlighting the development of right ventricular (RV) failure while on ECMO. We conducted a retrospective multicenter observational study including 70 patients who were placed on veno-venous (VV)-ECMO for respiratory failure at Mayo Clinic, Jacksonville, and Mayo Clinic, Rochester, between January 2018 and June 2022 and had at least two post-ECMO transthoracic echoes. The primary outcomes were the incidence and progression of RV dysfunction and dilatation. The secondary outcome was in-patient mortality. Among 70 patients in our cohort, 60.6% had a normal RV function at the time of ECMO placement, whereas only 42% had a normal RV function at the second post-ECMO echo. On multinomial regression, a moderate decrease in RV function was associated with ECMO flow (odds ratio [OR] = 2.32, p = 0.001) and ECMO duration (OR = 1.01, p = 0.01). A moderately dilated RV size was also associated with ECMO flow (OR = 2.62, p < 0.001) and ECMO duration (OR = 1.02, p = 0.02). An increasing degree of RV dysfunction was associated with worse outcomes. Our study showed that the increasing duration and flow of VV-ECMO correlated with progressive RV dilatation and dysfunction, which were associated with poor survival.

The evidence on indications, outcomes, and complications with the use of extracorporeal membrane oxygenation (ECMO) in the setting of interstitial lung disease (ILD) is limited in the existing literature. We performed a systematic review and meta-analysis for the use of ECMO in the setting of ILD to study the prognostic factors associated with in-hospital mortality. Eighteen unique studies with a total of 1,356 patients on ECMO for ILD were identified out of which 76.5% were on ECMO as a bridge to transplant (BTT) and the rest as a bridge to recovery (BTR). The overall in-hospital mortality was 45.76%, with 71.3% and 37.8% for BTR and BTT, respectively. Among the various prognostic factors, mortality was lower with younger age (mean difference = 3.15, 95% confidence interval [CI] = 0.82–5.49), use of awake veno-arterial (VA)-ECMO compared to veno-venous (VV)-ECMO (unadjusted odds ratio [OR] = 0.22, 95% CI = 0.13–0.37) in the overall cohort. In the setting of BTT, the use of VA-ECMO had a decreased hazard ratio (HR) compared to VV-ECMO (adjusted HR = 0.34, 95% CI = 0.15–0.81, p = 0.015). The findings of our meta-analysis are critical but are derived from retrospective studies with small sample sizes and thus are of low to very low-GRADE certainty.

Despite the frequent use of prophylactic antibiotics in hospitals for extracorporeal membrane oxygenation (ECMO) patients, the Extracorporeal Life Support Organization (ELSO) Infectious Disease Task Force does not recommend routine antibiotic prophylaxis due to a lack of compelling evidence. We assessed the effectiveness of prophylactic antibiotics in ECMO patients. We conducted a comprehensive search of multiple databases from their inception up to September 6, 2023, on various databases using keywords like “antibiotics,” “prophylaxis,” “extracorporeal membrane oxygenation,” and “ECMO.” Newcastle-Ottawa Scale (NOS) was used to assess the quality of the included research. We collected data using Microsoft Excel version 2016, mean and standard deviations were calculated for continuous data, while frequencies and percentages were calculated for binomial data. A total of three studies was included in the review with a total of 8,954 participants, of which 4,483 (50.06%) received antibiotic prophylaxis, and 1,131 (25.22%) were female. The administration of antibiotics prophylactically was associated with reduction in rate of mortality, the risk of infections, and complications like acute kidney injury and diarrhea. Although there have been some benefits on antibiotic prophylaxis, prospective research, and possibly the creation of tailored, ECMO-specific bundles will be needed to identify efficient ways to prevent ECMO infection.

The application of cryotherapy in the extraction of airway blood clots has gained increased precedence over Fogarty catheter and biopsy forceps. The cryoprobe, passed through a flexible bronchoscope, adheres and aids in the removal of foreign body through cryoadhesion within minutes. Besides blood clots, this method was found to be extremely efficient in removing different kinds of foreign bodies including food particles like peanuts, pills, and inspissated mucus.