Ye In Christopher Kwon

Background/Objectives: Following heart transplantation (HT), a subset of patients will require an early or late permanent pacemaker (PPM). We explored risk factors and outcomes associated with PPM implantation in this population. Methods: Using the United Network for Organ Sharing (UNOS) database, we identified all adult patients undergoing HT from 2013 to 2023 who received a PPM early (prior to discharge) or late (>6 months post transplant). Propensity score matching (PSM) was used for control cohorts was. Primary outcomes included recipient survival at 30 days and 1 and 5 years. Predictors of early and late PPM, as well as post-PPM mortality, were assessed using Cox and logistic regression models. Kaplan–Meier survival curves were compared using a log-rank test. Results: Following PSM, the early PPM cohort included 354 patients, and the late PPM cohort included 554 patients. Early PPM patients showed similar 30-day and 1- and 5-year survival (p = 0.582, 0.421, and 0.2844 respectively) but lower rates of graft failure (1.1% vs. 4%, p = 0.017) and primary graft dysfunction (PGD) (1.7% vs. 4.2%, p = 0.046). Late PPM patients had reduced survival at 30 days and 1 year but not at 5 years (p < 0.001, p = 0.0023, 0.050 respectively). Neither early nor late PPM was independently associated with increased risk of mortality after HT. Donation after Circulatory Death (DCD) organs were associated with a lower risk of early PPM (aOR = 0.409, p = 0.020). Late PPM patients showed higher rates of PGD (2.5% vs. 0.5%, p = 0.007). Conclusions: Early or late PPM is not an independent risk factor for mortality after HT, but differing short-term morbidity and mortality are observed.

BACKGROUND: Heart transplantation in the United States is increasingly performed amid expanding Medicare and Medicaid coverage. We analyzed the impact of recipient insurance trajectories on long-term graft and recipient survival following the 2018 United Network for Organ Sharing heart allocation change. METHODS: Adults aged 18 to 64 years undergoing first-time heart transplantation between October 2018 and March 2024 were identified from the national United Network for Organ Sharing solid-organ transplant registry. Recipients surviving ≥1 year were stratified by insurance trajectory across waitlisting, transplantation, and 1-year follow-up into 5 groups: continuous private, continuous public (Medicaid, Medicare, or Veterans Affairs), private-to-public transition, public-to-private transition, and multiple transitions. All-cause mortality and graft failure through 5 years posttransplant were assessed using Kaplan-Meier and multivariable Cox proportional hazards models with continuous private insurance as the referent. RESULTS: Among 15 864 recipients (mean age, 50.9±11.4 years; 31% female), 42.5% had continuous private insurance, 33.9% continuous public, 12.6% private-to-public, 4.8% public-to-private, and 6.3% multiple transitions. Five-year mortality was higher with continuous public insurance (15.1%) and multiple transitions (14.6%) than with continuous private (11.9%), and 5-year graft failure followed the same pattern (4.3% and 3.6% versus 3.2%). Continuous public insurance (hazard ratio [HR], 1.27 [95% CI, 1.15–1.40]) and multiple transitions (HR, 1.19 [95% CI, 1.12–1.43]) were independently associated with increased mortality. Continuous public insurance (HR, 1.29 [95% CI, 1.06–1.56]), private-to-public transition (HR, 1.32 [95% CI, 1.03–1.71]), and multiple transitions (HR, 1.09 [95% CI, 1.07–1.55]) elevated graft failure risk; public-to-private transition was associated with lowered risk (HR, 0.73 [95% CI, 0.45–0.92]). Residence in distressed communities was independently associated with increased mortality (HR, 1.21 [95% CI, 1.12–1.57]) and graft failure (HR, 1.31 [95% CI, 1.20–1.41]). CONCLUSIONS: Public insurance and insurance instability are associated with worse heart transplantation outcomes, while gaining private insurance was associated with improved outcomes, highlighting disparities in posttransplant care.

Acute antibody-mediated cardiac allograft rejection (AMR) can lead to SCAI Stage D cardiogenic shock, frequently necessitating escalation to extracorporeal

Objectives: With persistent donor shortages limiting lung transplantation (LT), optimizing the use of extended-criteria donors is essential. Asphyxiation (AXP) and donation after circulatory death (DCD) donors both experience hypoxic–ischaemic injury, raising concern for graft performance. We evaluated the long-term outcomes of AXP donor LT and the effect of ex vivo lung perfusion (EVLP) on survival. Methods: Adult recipients (≥18 years) of primary LT (2014-2024) in the United Network for Organ Sharing registry were stratified by donor cause of death: AXP vs non-AXP. Survival was estimated by Kaplan–Meier analysis, and multivariable Cox regression identified factors associated with mortality. Subgroup analyses examined EVLP and DCD vs donation after brain death (DBD) cohorts. Results: Among 26 334 LT recipients, 1406 (5.3%) received AXP donor lungs. Asphyxiation donors were more frequently DCD (9.5% vs 6%, P < .001). Ten-year recipient (25.2% vs 27.4%; P = .67) and graft (24.1% vs 26.8%; P = .72) survival were comparable, and AXP status was not independently associated with mortality after adjusting for allocation era (HR 1.01, 95% CI, 0.91-1.11, P = .908). However, EVLP use in AXP lungs correlated with decreased 3-year survival (55.3% vs 74.1%; P = .035). Sensitivity analyses demonstrated significant differences among the 4 donor subgroups (DCD-AXP, DCD non-AXP, DBD-AXP, and DBD non-AXP) on overall comparison (P = .008), with DCD-AXP recipients exhibiting numerically the highest 5-year survival rates. Conclusions: AXP donor lungs provide comparable long-term outcomes, and DCD-AXP grafts do not appear to confer inferior survival. The interaction between AXP and EVLP use warrants further study to refine donor reconditioning strategies.

Background/Objectives: Acute hemodynamic collapse is a rare but deadly complication of transcatheter aortic valve replacement (TAVR) that can require temporary mechanical circulatory support (tMCS). Using a statewide collaborative, we conducted a focused analysis on the incidence and outcomes associated with the use of tMCS during TAVR as hemodynamic rescue. Methods: We identified adult patients who underwent TAVR between September 2012 and September 2024 within the statewide collaborative and stratified them based on if tMCS was needed. Baseline patient characteristics and risk factors associated with tMCS use were analyzed as well as the impact of tMCS on outcomes. Results: We identified 7735 patients who underwent TAVR. A total of 44 (0.57%) patients required tMCS. Patients requiring tMCS were more likely to have histories that included diabetes, concurrent mitral regurgitation, prior MI, or NYHA class III or IV. These patients also experienced more emergent procedures and were more likely to require inotropic support. Patients experienced significantly worse outcomes following tMCS rescue during TAVR, with 18% requiring conversion to surgical approach (vs. 1%, p < 0.001) and 37% of tMCS patients experiencing cardiac arrest, compared to 1% of those who did not need tMCS (p < 0.001). Thirty-day mortality was worse for patients requiring tMCS (p < 0.001). MCS usage was independently associated with the need for further procedures. Conclusions: Unplanned, emergent tMCS during TAVR as hemodynamic rescue represents significant risk of complications and should be utilized judiciously in cases of acute hemodynamic collapse.