Supreet S. Randhawa

Opsoclonus is an ocular dyskinesia characterized by involuntary, arrhythmic, multidirectional saccades. In pediatrics, opsoclonus is most commonly attributed to the rare neuroinflammatory disorder opsoclonus‐myoclonus‐ataxia syndrome (OMAS), typically considered a paraneoplastic syndrome associated with neural crest tumors. However, opsoclonus can manifest as a symptom of other disease processes including toxic, metabolic, and genetic etiologies, and there is a paucity of literature focusing on the differential diagnoses and etiologic workup of opsoclonus in children. This review aims to address this knowledge gap with the ultimate goal of providing a schema facilitating the evaluation of a pediatric patient presenting with opsoclonus.

Objectives: Heart transplant primary graft dysfunction, defined as severe ventricular dysfunction within 24 hours after allograft reperfusion, is the leading cause of early mortality following heart transplantation. This study used plasma metabolomics to identify metabolic signatures associated with severe primary graft dysfunction. Methods: This single-centre study collected blood samples from 60 adult heart transplant recipients 12 and 24 hours following graft reperfusion. Patients were categorized according to the International Society for Heart and Lung Transplantation guidelines. Samples underwent metabolomics analysis via liquid chromatography-mass spectrometry. Linear models for microarray data were used to identify the metabolic effects of primary graft dysfunction, time, and their interaction, with pathway enrichment analysis and focused analysis of identified metabolites to interpret biological patterns. Results: Among the 60 patients included in this study, 8 developed severe primary graft dysfunction. Severe primary graft dysfunction was associated with coordinated metabolic alterations central to cellular energetics, including altered amino acid and nitrogen handling, broad acylcarnitine accumulation, and selective perturbations of tricarboxylic acid cycle intermediates. Temporal analyses identified divergent metabolite trajectories between groups, with succinate demonstrating the most pronounced divergence over time, reflecting failure to normalize central energy metabolism in severe primary graft dysfunction. Redox-related metabolites demonstrated patterns consistent with activation of antioxidant buffering. Conclusions: Severe primary graft dysfunction is characterized by a failure to restore cellular energy metabolism, reflected by coordinated upstream substrate accumulation and a distinct temporal pattern of succinate elevation. As an established metabolic signature of ischaemia-reperfusion injury, the succinate trajectory provides a biologically plausible link between impaired energetic recovery and downstream oxidative stress. Although exploratory, these findings support a coherent metabolic framework distinguishing recovery from persistent energetic stress in severe primary graft dysfunction.

Background/Objectives: Acute Kidney Injury (AKI) requiring continuous renal replacement therapy (CRRT) has historically been a contraindication for left ventricular assist device (LVAD) implantation. However, advancements in magnetically levitated (MagLev) LVADs warrant reevaluation. Methods: A retrospective review of adult LVAD recipients at a tertiary center (2009–2024) was performed. Patients were stratified by preoperative CRRT status and LVAD type. Baseline characteristics and perioperative morbidity, Kaplan–Meier survival estimates, restrictive mean survival time (RMST), and Cox proportional hazards models were assessed. Results: Among 312 MagLev LVAD recipients, 22 (7.1%) required preoperative CRRT. Compared to non-CRRT patients, the CRRT group had higher illness severity (INTERMACS 1 or 2: 95% vs. 71%, p = 0.019). Despite this, preoperative CRRT was not associated with worse mortality within the MagLev cohort at 30 days (9.1% vs. 7.9%), 1 year (18.2% vs. 17.9%), or 2 years (31.8% vs. 20.7%; p = 0.31). RMST at 1 year was also similar (305 vs. 311 days; p = 0.85). In contrast, patients on CRRT receiving non-MagLev devices had significantly worse outcomes, with 30-day, 1-year, and 2-year mortality rates of 57.1%, 71.4%, and 78.6%, respectively. RMST analysis showed a 170-day survival advantage at 1 year for MagLev vs. non-MagLev CRRT patients (p < 0.01). Conclusions: In this single-center cohort, preoperative CRRT was not associated with higher mortality among MagLev LVAD recipients and may challenge traditional contraindications against LVAD therapy. Further investigations using larger cohorts are necessary to further evaluate these findings and delineate patient subgroups that may derive the greatest clinical benefit.

Background/Objectives: Donation after circulatory death (DCD) has emerged to expand the heart-donor pool, but many DCD donors have risk factors such as cocaine or methamphetamine use. Stimulant use can cause coronary vasospasm and premature coronary artery disease, leading to routine donor coronary angiography (left heart catheterization, LHC) for coronary screening. However, performing LHC in DCD donors is challenging. We examined whether omitting LHC in stimulant-exposed DCD donors affects outcomes. Methods: A retrospective analysis was performed using the United Network for Organ Sharing (UNOS) database (2019–2024) to identify adult heart transplant recipients from DCD donors with documented cocaine or amphetamine use. Donors were stratified by whether antemortem LHC was performed. The primary outcome was 1-year recipient survival; secondary outcomes included graft failure and acute rejection. Kaplan–Meier survival curves and Cox regression analyses were performed. Results: A total of 485 DCD heart transplant recipients were identified; 135 (28%) donors underwent LHC and 350 (72%) did not. Recipient characteristics were similar between groups. No significant differences in 30-day (6% vs. 3%; p = 0.11), 90-day (6% vs. 3%; p = 0.21), or 1-year survival (7% vs. 6%; p = 0.48) were observed between the LHC and non-LHC cohorts. Graft failure and complication rates were also similar. However, among stimulant-exposed DCD donors with diabetes, an absence of LHC was associated with higher recipient mortality (HR 5.86, 95% CI: 1.57–21.87; p = 0.008). Conclusions: Routine donor coronary angiography may be unnecessary for stimulant-exposed DCD donors without additional risk factors. Omitting LHC did not compromise transplant outcomes. A selective LHC approach for high-risk DCD donors (e.g., diabetic donors) could safely expand the donor pool.