Alexander Martin Bernhardt

Objectives: Superior survival outcomes have been reported for younger patients receiving durable left ventricular assist devices (LVADs) in Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). We explored whether these findings extend to contemporary European practice leveraging on EUROMACS (European Registry for Patients with Mechanical Circulatory Support). Methods: Adult patients undergoing implantation of current-generation magnetically levitated LVADs in EUROMACS were stratified according to age groups. The primary outcome was 5-year on-device survival, censored at heart transplantation (HT) or LVAD explantation. Secondary outcomes included LVAD explant for myocardial recovery and survival free from major adverse events (bleeding, stroke, device-related infection, or device malfunction). Death incidence accounting for HT and support cessation as competing risks was also calculated. Results: A total of 2850 patients undergoing HeartMate 3 implantation were included (<50 years: 23.5%; 50-59 years: 29.7%; 60-69 years: 38.0%; ≥70 years: 8.8%). Younger patients had fewer comorbidities, a higher prevalence of non-ischaemic cardiomyopathy, and INTERMACS profile ≤3. Younger patients had superior on-device 5-year survival (<50 years: 74.7%; 50-59 years: 65.5%; 60-69 years: 53.9%; ≥70 years: 48.8%; P < .001) and LVAD explantation for myocardial recovery (<50 years: 4.3%; 50-59 years: 1.8%; 60-69 years: 2.3%; ≥70 years: 0.4%; P = .031). Accounting for competing outcomes, the 5-year cumulative incidence of death was lowest among younger patients (<50 years: 20.8%; 50-59 years: 29.1%; 60-69 years: 40.8%; ≥70 years: 49.5%; P < .001), driven by higher HT rates. Survival free from bleeding was significantly higher in younger patients (P < .001). In contrast, 5-year freedom from stroke, device-related infection, and device malfunction was similar across age groups. Conclusions: In contemporary European practice, patients <50 years undergoing LVAD implant had high 5-year survival approaching that reported in cohorts of patients listed for HT. These findings support further investigation of prolonged LVAD support before HT as a potential strategy to maximize lifetime benefit in selected motivated younger candidates.

Background: Driveline infections (DLIs) remain the predominant device‐specific complication in patients supported by left ventricular assist devices (LVADs) serving as a major source of morbidity, recurrent hospitalization, and mortality. Despite their clinical impact, the prevention and early management of DLIs lack standardization, particularly within outpatient and home‐based care environments. Methods and Objectives: The original 2020 DESTINE proposal introduced a standardized dressing protocol and a prevention‐oriented staging system for driveline exit‐site management. However, subsequent clinical real‐world experience revealed limitations, including overly complex early‐stage subcategorization and the absence of contemporary guidance on wound care, including fixation strategies, antiseptic agents, and adjunctive therapies. Updated Recommendations: DESTINE 2.0 provides expert recommendations to address these gaps. The updated framework features a streamlined five‐stage system that consolidates previous subcategories into unambiguous, actionable clinical stages. Enhanced recommendations are provided for driveline immobilization, stage‐stratified antiseptic agent selection, and skin barrier preservation. Furthermore, the protocol incorporates adjunctive therapies including cold atmospheric plasma and closed‐incision negative pressure wound therapy. Expanded guidance covers modifiable patient‐level risk factors, perioperative prophylaxis, showering safety, caregiver education, digital documentation, and stage‐directed antibiotic therapy. Conclusion: By providing a practical, integrated framework applicable to multidisciplinary care settings, DESTINE 2.0 aims to optimize infection‐free survival, minimize healthcare utilization, and improve quality of life for patients on long‐term mechanical circulatory support.

Objectives: Microaxial flow pumps (mAFP) effectively bridge patients with cardiogenic shock to durable left ventricular assist device (dLVAD) implantation. The partial-support mAFPs provide only up to 3.5 L/min, which might be insufficient for an effective circulatory support and preconditioning for a dLVAD implantation. Alternatively, patients with refractory shock on partial support may benefit from an escalation to a full-support mAFP. Methods: A retrospective analysis of 130 patients was performed across 17 European cardiac centres who underwent dLVAD implantation following mAFP with or without venoarterial extracorporeal life support (VA-ECLS) between February 2015 and August 2022. Ninety-two patients (70.8%) were bridged on partial-support mAFP, while 38 patients (29.2%) underwent an escalation to full-support mAFP. Results: Median support duration was significantly longer in the escalation group (7 days [4, 11] vs 12 days [9, 21], P < .001). Patients in the escalation group were more likely to be weaned from VA-ECLS before dLVAD implantation, 10 (71.4%) vs 6 (11.3%), P < .001. Thirty-day survival was similar between the escalation and no-escalation groups, 89.5% vs 84.8% (IPTW-weighted OR, 1.00 [95% CI, 0.46-2.22], P = .992). Estimated 1-year survival was higher in the escalation group: 84.0% [95% CI, 73.0-96.6] vs 63.7% [95% CI, 54.3-74.6], HR 0.41 [95% CI, 0.17-0.99], P = .048. Patients with a combination of partial-support mAFP and VA-ECLS had a higher mortality risk than all other patients, HR 2.06 [95% CI, 1.16-3.36], P = .013. Conclusions: In patients with partial-support mAFP and concomitant VA-ECLS, an escalation to a full-support mAFP may translate to improved survival and should be considered to facilitate VA-ECLS weaning.

Background: Cardiogenic shock (CS) remains a leading cause of early death in acute cardiac care, with 30-day mortality frequently approaching 40–50% despite advances in revascularization and critical care pathways. Contemporary CS management has progressed through standardized definitions, staging systems, and phenotyping frameworks that support earlier recognition and a more disciplined escalation strategy. However, evidence-based therapies that consistently reduce mortality remain limited, and device-related complications and heterogeneous etiologies continue to constrain outcome gains. Summary: Temporary mechanical circulatory support (tMCS) provides rapid hemodynamic stabilization, augments end-organ perfusion, and enables time for revascularization, recovery, durable left ventricular assist device (LVAD) implantation, or transplantation. The major tMCS modalities used in current practice include intra-aortic balloon pump, percutaneous microaxial flow pumps, left atrial-to-arterial bypass devices, and venoarterial extracorporeal membrane oxygenation (VA-ECMO), with dedicated right-sided support strategies for right ventricular failure. Selection should be driven by (i) shock stage and trajectory, (ii) dominant ventricular lesion (LV, RV, or biventricular), (iii) oxygenation need, (iv) anatomical constraints and access options, and (v) intent (bridge to decision, recovery, durable LVAD, or transplant). Randomized evidence supports immediate culprit lesion revascularization for myocardial AMI-CS and suggests benefit from routine microaxial flow pump support in carefully selected AMI-CS patients without major hypoxic brain injury risk, albeit at the cost of higher bleeding and limb ischemia. In contrast, routine early VA-ECMO in infarct-related CS has not demonstrated mortality benefit in randomized trials and is associated with increased complications; therefore, VA-ECMO should be reserved for selected phenotypes, including refractory shock with severe hypoxemia, profound biventricular failure, or circulatory collapse, and should be embedded within an explicit unloading, anticoagulation, limb perfusion, and weaning protocol. Key Message: tMCS implantation and management should be based on cardiogenic severity and phenotype.

Aims: Modulation of cardiac neural control is increasingly explored to treat cardiac arrhythmias. While the atrially located ganglionated plexus (GPs) have been studied intensively, characterization of ventricular GPs is sparse. This proof-of-principle study aimed to assess the role of the posterior descending GP (PDGP) for neural control of cardiac electrophysiology, while offering a translational roadmap into clinical practice. Methods and results: Since an initial systematic literature review revealed the PDGP as a small, consolidated GP on the posterior left ventricle (LV) in dogs, swine, and humans, we subsequently conducted morphological C57BL/6 murine studies (n = 43) indicating ventricular GPs in only 10% of hearts. Based on our initial findings, in a proof-of-principle study analysing 4300 local unipolar electrograms from a multi-electrode sock, the impact of functional PDGP modulation was studied in an ex vivo retrograde-perfused porcine model. Wave propagation characteristics determined by epicardial activation mapping demonstrated increased dispersion of conduction velocity during high-frequency (8.52 ± 2.24 radian vs. 2.79 ± 0.89 radian; P = 0.018) and nicotine stimulation (19.79 ± 6.49 radian vs. 2.79 ± 0.89 radian; P = 0.044) compared to paced rhythm. High-frequency stimulation prolonged activation recovery intervals in the posterior (257.8 ± 6.7 ms vs. 244.8 ± 1.9 ms; P = 0.044) and basal (258.1 ± 4.2 ms vs. 244.8 ± 1.9 ms; P =0.039) right ventricle compared to the posterior LV. Analysis of explanted human hearts confirmed the presence of the PDGP within epicardial adipose tissue near its eponymous coronary artery and the posteromedial left atrial GP. Three-dimensionally reconstructed human hearts suggested the PDGP localization characterized by inter-patient anatomical variability. Conclusion: The present translational approach to ventricular innervation demonstrates first evidence of the functional relevance of the PDGP, with morphological findings indicating species-related differences. Novel imaging modalities might pave the way for future functional and therapeutic interventions.