Purpose In this study we sought to: (1) objectively assess the risk related to various pre-transplant recipient and donor characteristics; (2) devise a preoperative risk stratification score (RSS) based on pre-transplant recipient and donor characteristics predicting graft loss at 1-year; and (3) define different risk strata based on RSS. Methods UNOS provided de-identified patient-level data. Analysis included 11,703 orthotopic heart transplant recipients aged ≥ 18 years and transplanted between 1/1/01-12/31/07. The primary outcome was 1-year graft failure. Multivariable logistic regression analysis (backward p-value < 0.20) was used to determine the relationship between pre-transplant characteristics and 1-year graft failure. Using the odds ratio for each identified variable, a RSS was devised. RSS strata were defined by calculating ROC curves and stratum specific likelihood ratios. Results The strongest negative predictors of 1-year graft failure included: RVAD-only, ECMO, renal failure, extracorporeal LVAD, total artificial heart, and advanced age. Threshold analysis identified five discrete RSS strata: low risk (LR, RSS: <2.55; n=3242, 27.7%), intermediate risk (IR, RSS: 2.55-5.72; n=6347, 54.2%), moderate risk (MR, RSS: 5.73-8.13; n=1543, 13.2%), elevated risk (ER, RSS: 8.14-9.48; n=310, 2.6%), and high risk (HR, RSS: >9.48; n=261, 2.2%). The 1-year actuarial survival (%) in the LR, IR, MR, ER, and HR groups were 93.8, 89.2, 81.3, 67.0, and 47.0, respectively. Conclusion Pre-transplant recipient variables significantly influence early and late graft failure following heart transplantation. RSS may improve organ allocation strategies by reducing the potential negative impact of transplanting candidates who are at a high risk for poor postoperative outcomes.

Background AngioVac is a new device for filtering intravascular thrombi and emboli. Publications on the device are limited and underpowered to objectively estimate its safety and efficacy. We aimed to overcome this by performing a meta‐analysis on the results of AngioVac for treating venous thromboses and endocardial vegetations. Methods A systematic literature review was performed to identify all articles reporting cardiac vegetation and/or thrombosis extraction using AngioVac. Endpoints were successful removal, operative mortality, conversion to open surgery, hospital stay, recurrent thromboembolism, and follow‐up mortality. Random effect model was used, and pooled event rates (PERs) and incidence rate (IR) were calculated. Results A total of 42 studies with 182 patients (81 vegetation and 101 thrombosis) were included. Overall mean follow‐up times were 3.1 and 0.7 years in vegetation and thrombosis patients, respectively. The PERs for successful removal were 74.5 (confidence interval [CI]: 48.2‐90.2), 80.5 (CI: 70.0‐88.0), and 32.4 (CI: 17.0‐52.8) in vegetation, right atrial/caval venous thrombi, and pulmonary emboli (PE) patients, respectively. The PERs for operative mortalities were 14.6 (CI: 7.7‐25.8), 14.8 (CI: 8.5‐24.5), and 32.3 (CI: 15.1‐56.3), respectively. The PERs for conversion to open surgery were 25.0 (CI: 9.3‐51.9) and 12.3 (CI: 5.4‐25.6) in vegetation and thrombosis patients, respectively. The IR of recurrent thromboembolism was 0.18 per person per year (PPY) (CI: 0.00‐14.69) in vegetation and 0.19 PPY (CI: 0.08‐0.48) in thrombosis patients. IR of follow‐up mortality was 0.37 PPY (CI: 0.11‐1.21) in thrombosis patients. Conclusions AngioVac is a viable option for extracting right‐sided vegetations and right atrial/caval venous thrombi. Rates of successful extraction and mortality are significantly worse for PE.

The mid-priority groups (eg, 50-59, 60-69, 70-79) seem to achieve the greatest survival benefit from transplantation. Although low-priority candidates comprise the majority of transplant recipients, survival benefit in this group seems to be less than in other groups given the low risk of death on the waiting list. As expected, both the time to transplant and survival on the waitlist are lower in the higher-priority strata (eg, 80-89 and 90+). However, their net survival benefit was likewise relatively low as a result of their poor posttransplant survival.

Cyclin-dependent kinase inhibitor p27, a critical determinant for cell cycle progression, is an important regulation target of mitogenic signals during arterial injury. In this study, we show in rat aortic smooth muscle cells that PDGF-BB down-regulated p27 protein and mRNA in an ERK-dependent mechanism. Inhibition of ERK, but not other subtypes of the mitogen-activated protein kinase family, prevented the reduction of p27 protein and mRNA. Conversely, direct activation of ERK via adenovirus-mediated expression of a constitutively active form of MEK led to a reduction of p27 protein and mRNA, further supporting the central role of ERK in regulation of p27 expression. Rapamycin, which potently inhibited PDGF-induced activation of p70 S6 kinase as well as proliferation of smooth muscle cells, did not alter the expression of p27. To delineate the molecular mechanism underlying the p27 down-regulation, we examined the effect of PDGF-BB on p27 promoter activity as well as mRNA stability. Stimulation with PDGF-BB significantly shortened the half-life of p27 mRNA without affecting its promoter activity. To further understand the PDGF-stimulated p27 mRNA turnover, we inserted the 5-and/or 3-untranslated regions of p27 cDNA into a non-PDGF-responsive luciferase gene. Only those chimeric genes that contained the 3-untranslated region responded to PDGF-BB with reduced expression. Moreover, inhibition of ERK completely prevented the effect of PDGF on the chimera expression. In summary, our data suggest that p27 is down-regulated by PDGF-BB in vascular smooth muscle cells through an ERK-dependent posttranscriptional mechanism.

Pericardiectomy can be performed with low mortality and immediate improvement in hemodynamics. Those patients with compromised cardiac output, abnormal hepatic or renal function, or with previous radiation therapy have reduced long-term survival.

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A 41-year-old female presented with a large anterior mediastinal mass adjacent to the heart. Biopsy demonstrated lymphoma. Upon administration of chemotherapy, she developed cardiogenic shock requiring a 5-day course of extracorporeal membrane oxygenation (ECMO) as a bridge through her treatment. After one cycle of chemotherapy, ECMO was discontinued and the patient completed her course of chemotherapy and recovered to hospital discharge.