Alice Li Zhou

All Publications

• From Proxy to Precision: The Growing Need to Capture True Warm Ischemic Time in Donation-After-Circulatory-Death Heart Transplantation. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation Berg, A. R., Choi, A. Y., Zhou, A., MacArthur, Y. J. 2025

  View details for DOI 10.1016/j.healun.2025.08.021

  View details for PubMedID 40902960

• Outcomes of liver transplants utilizing donors from outside the contiguous United States AMERICAN JOURNAL OF SURGERY Jenkins, R. T., Hapuarachchy, B. L., Shah, M. M., Larson, E. L., Zhou, A. L., Farhat, D. J., Ruck, J. M., Rached, H., King, E. A., Philosophe, B., Kassam, A. 2025; 249: 116568

  Abstract

  Expanding the liver donor pool includes reconsidering geographic characteristics. We evaluated demographics, trends, and outcomes of transplants from donors outside the contiguous US.Adult liver-only transplants from 2010 to 2022 were categorized by donor location (mainland US vs. non-mainland) using national registry data. Post-transplant survival was evaluated using time-to-event analysis, univariate and multivariable Cox regression.1531 (1.5 ​%) liver transplants utilized non-mainland organs (991 performed in mainland US). Non-mainland to mainland donors were older, smoked less, had a lower BMI, and less steatosis (all p ​< ​0.05). Non-mainland organs traveled further (1241 vs. 84 miles,p ​< ​0.01) with longer ischemic times (8.6 vs. 5.9 ​h,p ​< ​0.01). Length of stay (p ​= ​0.80) and acute rejection (p ​= ​0.14) did not differ. Non-mainland recipients had similar survival at 1-(aHR 1.02, p ​= ​0.85), 5-(aHR 0.93, p ​= ​0.38), and 10-years (aHR 0.96, p ​= ​0.56).Non-mainland recipients had similar LOS and survival despite longer distance and cold ischemic time, emphasizing further consideration for non-mainland transplantation.

  View details for DOI 10.1016/j.amjsurg.2025.116568

  View details for Web of Science ID 001560928600001

  View details for PubMedID 40848472

• Safety of internal thoracic artery use in patients with prior mediastinal radiation undergoing coronary artery bypass grafting: a Maryland statewide propensity-matched analysis HEART Zhou, A. L., Chinedozi, I. D., Holmes, S. D., Gammie, J. S., Patel, D., Akbar, A. F., Alejo, D., Lawton, J., Whitman, G., Salenger, R., Briscoe, J. B., Darby, Z. E., Cameron, D., Wang, H., Maryland Cardiac Surg Quality Initiative MCSQI 2025

  Abstract

  The safety of internal thoracic artery (ITA) grafting in patients undergoing coronary artery bypass grafting (CABG) with prior mediastinal radiation remains controversial due to concerns regarding compromised sternal perfusion and radiation-induced injury. This study evaluated whether prior mediastinal radiation is associated with adverse perioperative outcomes in patients undergoing CABG with ITA grafting.We conducted a retrospective cohort study using the Maryland Cardiac Surgery Quality Initiative (MCSQI) database. A total of 29 206 patients who underwent CABG with ITA use between 1 July 2011 and 31 March 2023 were analysed. Patients with and without prior mediastinal radiation were propensity-matched (1:10) using the nearest neighbour method. The primary outcome was the composite of operative mortality and deep sternal wound infection (DSWI). Secondary outcomes included other infectious complications, major morbidities, postoperative hospital length of stay, and 30-day readmission.Among 29 206 patients, 294 (1%) had a history of mediastinal radiation. Patients with prior radiation were older (median (IQR) 70 (60-75) vs 66 (59-73) years, p<0.001), more frequently female (66% vs 25%, p<0.001) and had a higher prevalence of chronic lung disease (31% vs 19%, p<0.001). After propensity matching, no significant differences were observed in the primary composite outcome (2% vs 3%, p=0.53) or in secondary outcomes.In this large retrospective cohort, prior mediastinal radiation was not associated with an increased risk of perioperative adverse events in patients undergoing CABG receiving ITA grafts. These findings demonstrate no evidence of safety concerns with the use of ITA grafting in patients with prior radiation and challenge the practice of excluding these patients from arterial revascularisation strategies.

  View details for DOI 10.1136/heartjnl-2025-325949

  View details for Web of Science ID 001558969200001

  View details for PubMedID 40829862

• New kidney-after-heart allocation policy in the United States: Who would benefit from a rescue kidney? JOURNAL OF HEART AND LUNG TRANSPLANTATION Zhou, A. L., Akbar, A. F., Rizaldi, A. A., Ruck, J. M., Larson, E. L., Rokui, S., Paneitz, D. C., King, E. A., Kilic, A. 2025; 44 (7): 1083-1092

  Abstract

  The new rescue kidney policy in the United States was implemented in June 2023. To estimate its potential impact, we investigated a historic cohort of heart transplant (HT) recipients who would have been eligible for a kidney-after-heart transplant under this policy.Adult heart-only recipients from January 1, 2000 to March 31, 2023 in the United Network for Organ Sharing database were categorized by retroactively applying eligibility criteria from the new policy: estimated glomerular filtration rate (eGFR)≤20ml/min, creatinine clearance (CrCl) ≤20ml/min, or dialysis 60-365 days post-HT. We evaluated outcomes of eligible recipients.Of 45,833 HT recipients, 840 (1.8%) were eligible for a rescue kidney. Eligible recipients had higher median age (58 vs 56 years, p<0.001) and serum creatinine (1.4 vs 1.2, p<0.001), and were more likely to be status 1A in the pre-2018 allocation era (63.4% vs 51.9%, p<0.001) and status 1 in the post-2018 allocation era (13.9% vs 9.1%, p=0.003). Survival at 1 year conditional on 60-day survival was worse for eligible recipients (50.8% vs 96.3%; HR 17.6 [95% CI: 15.8-19.6], p<0.001). Post-HT, 607 (72.3%) eligible recipients were never listed for kidney transplant (KT), of whom 486 (80.1%) died with a median time-to-death of 8.8 months. Among the 233 (27.7%) recipients listed for KT, 65 (27.9%) died/deteriorated on the waitlist and 99 (42.5%) received a KT (median 38.4 months post-HT).Half of recipients eligible for a rescue kidney did not survive to 1 year post-HT, and >70% were never listed for KT. The effects of the new policy on mitigating mortality in this challenging population will be paramount.

  View details for DOI 10.1016/j.healun.2025.01.002

  View details for Web of Science ID 001509158000011

  View details for PubMedID 39826634

  View details for PubMedCentralID PMC12145265

• Increasing risk of postlung transplant hospitalizations for infection: An analysis of recent trends. JHLT open Feng, S. N., Akbar, A. F., Zhou, A. L., Kalra, A., Agbor-Enoh, S., Merlo, C. A., Bush, E. L. 2025; 8: 100231

  Abstract

  Background: Despite advancements in lung transplantation (LT), infection remains a major cause of morbidity and mortality following LT. We examined trends in hospitalizations for infection in the first year after LT.Methods: We identified adult LT recipients in the United States(March1, 2018-March9, 2023) using the Organ Procurement and Transplantation Network database. We categorized transplants into 3 eras to account for the Composite Allocation Score allocation policy change and coronavirusdisease 2019: March2018 to March2020, March2020 to March2022, and March2022 to March9, 2023. One-year post-LT survival was compared using Kaplan-Meier survival analysis and Cox proportional hazards regression. Hospitalizations for infection were compared using multivariable logistic regression, adjusted for era and donor and recipient characteristics.Results: Of 12,388 LT recipients (median age=62, male=61.2%), hospitalization for infection in the first-year post transplant was 5.2% for patients transplanted from March 2018 to March 2020 (N=5,031), 7.6% from March 2020 to March 2022 (N=4,659), and 13.2% post-March 2022 (N=3,640) (p<0.001). Compared to March 2018 to March 2020, patients transplanted fromMarch 2020 to March 2022 (adjusted aoods ratio [aOR]=1.50, 95% confidence interval [CI]=1.26-1.79) and post-March 2022 (aOR=2.89, 95% CI=2.29-3.65) were more likely to be hospitalized for an infection. After adjustment, we found no significant difference in risk of death following LT for recipients transplanted between March 2020 and March 2022 (aHR=1.09, 95% CI=0.96-1.23, p=0.175) compared to March 2018 and March 2020. Post-March 2022 risk of death was elevated (aHR=1.21, 95% CI=1.04, 1.40, p=0.014).Conclusions: Odds of hospitalization for infection in the first year after LT performed between March 2020 and March 2022 and post-March 2022 were 1.50 and 2.89 times as high, respectively, as LT performed between March 2018 and March 2020.IRB NUMBERS: IRB00352819.

  View details for DOI 10.1016/j.jhlto.2025.100231

  View details for PubMedID 40144725

• Repair of giant pulmonary artery aneurysm and quadricuspid pulmonic valve with valve-sparing pulmonic root replacement. JTCVS techniques Verdi, K. G., Feng, I., Zhou, A. L., Woo, Y. J. 2025; 30: 69-72

  View details for DOI 10.1016/j.xjtc.2024.12.004

  View details for PubMedID 40242102

  View details for PubMedCentralID PMC11998398

• Repair of giant pulmonary artery aneurysm and quadricuspid pulmonic valve with valve-sparing pulmonic root replacement JTCVS TECHNIQUES Verdi, K., Feng, I., Zhou, A. L., Woo, Y. 2025; 30: 69-72

  View details for DOI 10.1016/j.xjtc.2024.12.004

  View details for Web of Science ID 001461129700001

• Utilization and outcomes of nonintubated extracorporeal membrane oxygenation as a bridge to lung transplant JOURNAL OF HEART AND LUNG TRANSPLANTATION Zhou, A. L., Jennings, M. R., Akbar, A. F., Ruck, J. M., Oak, A., Kalra, A., Larson, E. L., Casillan, A. J., Ha, J. S., Merlo, C. A., Bush, E. L. 2025; 44 (4): 661-669

  Abstract

  Nonintubated extracorporeal membrane oxygenation (ECMO) has been increasingly utilized for patients with severe respiratory failure. Since data on its use as a bridge to lung transplant remain limited, we evaluated its use in a national cohort.Adult lung-only transplant recipients bridged with ECMO May 4, 2005 to March 8, 2023 in the United Network for Organ Sharing database were categorized by use of ECMO and mechanical ventilation (MV) at transplant (ECMO+MV vs ECMO-only). We compared post-transplant intubation and ECMO at 72 hours, length of stay, and survival.The 1,599 transplants identified included 902 (56.4%) bridged with ECMO+MV and 697 (43.6%) bridged with ECMO-only. ECMO-only recipients had higher median age (52 vs 49 years, p < 0.001), shorter ischemic times (5.7 vs 6.0 hours, p = 0.003), and similar lung allocation scores (89.5 vs 89.6, p = 0.11). ECMO-only recipients had lower likelihood of intubation at 72 hours (56.5% vs 77.5%; adjusted odds ratio 0.33 [95% confidence interval (CI): 0.25, 0.42], p < 0.001) and shorter lengths of stay (28 vs 35 days; coefficient -0.19 [95% CI: -0.27, -0.11], p < 0.001). ECMO-only recipients had higher 90-day survival (92.1% vs 89.1%; adjusted hazards ratio (aHR) 0.69 [95% CI: 0.48, 0.99], p = 0.04) but similar 1-year (83.1% vs 81.5%; aHR 0.87 [95% CI: 0.67, 1.12], p = 0.27) and 5-year (54.6% vs 54.7%; aHR 0.98 [95% CI: 0.82, 1.17], p = 0.83) survival.Nonintubated ECMO bridge to lung transplant was associated with improved perioperative outcomes and short-term survival and should be considered for candidates requiring ECMO.

  View details for DOI 10.1016/j.healun.2024.10.021

  View details for Web of Science ID 001450294900001

  View details for PubMedID 39486773

• Mitral valve repair of papillary muscle rupture using multi-neochord reconstruction JTCVS TECHNIQUES Zhou, A. L., Feng, I., Verdi, K. G., Liou, K., Woo, Y. 2025; 29: 23-26

  View details for DOI 10.1016/j.xjtc.2024.10.018

  View details for Web of Science ID 001418858400001

• Early Hospital Readmission After Pediatric Liver Transplant: A Retrospective Analysis of the Society of Pediatric Liver Transplantation (SPLIT) Database PEDIATRIC TRANSPLANTATION Price, M. D., Ruck, J. M., Dilwali, N., Thomas, A., Zhou, A., Gorijavolu, R., King, E. A., Soc Pediat Liver Transplantat 2025; 29 (1): e14885

  Abstract

  Incidence of and risk factors for early hospital readmission (EHR) are poorly defined in pediatric liver transplant recipients. Therefore, we evaluated EHR incidence and risk factors for pediatric liver recipients in a nationally representative sample.Using the Society of Pediatric Liver Transplantation database, we retrospectively analyzed 2808 pediatric liver-only recipients transplanted 2011-2022. Recipient-, donor-, and center-level characteristics were evaluated as possible risk factors for EHR within 30 days of hospital discharge using multivariable modified Poisson regression.Overall, 23% (N = 642) of pediatric recipients experienced EHR. Independent risk factors for EHR include diabetes (adjusted relative risk [aRR] 2.33, 95% CI: 1.41-3.86, p = 0.001), history of malignancy (aRR 1.59, 95% CI: 1.19-2.11, p = 0.002), and shorter length of transplant hospitalization. Recipients in the shortest length of stay quartile (median [IQR] 8 [7-9] days) had a ninefold increased risk for EHR compared with recipients in the longest length of stay quartile (34 [28-48] days) (aRR 8.86, 95% CI: 5.68-13.81, p < 0.001). Incidence of EHR did not vary by transplant center and was not associated with other characteristics of the donor (DCD vs. not DCD), recipient (age, race, sex, and diagnosis), procedure (whole vs. split liver, ischemic time), or transplant center.We found the 30-day readmission rate for pediatric liver transplant recipients was 23%. Shorter hospital stays were a major risk factor for EHR, highlighting that longer initial transplant hospital stays may be beneficial for predischarge optimization and coordination of their complex care.

  View details for DOI 10.1111/petr.14885

  View details for Web of Science ID 001371684500001

  View details for PubMedID 39641150

• Outcomes of Liver Transplant for Hepatic Epithelioid Hemangioendothelioma CLINICAL TRANSPLANTATION Larson, E. L., Ciftci, Y., Jenkins, R. T., Zhou, A. L., Ruck, J. M., Philosophe, B. 2025; 39 (2): e70087

  Abstract

  Hepatic epithelioid hemangioendothelioma (HEH) is a rare indication of liver transplant with limited evidence.Adult recipients undergoing first-time liver-only transplant from 2002 to 2021 in the United States were identified using the UNOS/OPTN database. We compared post-transplant outcomes of recipients receiving liver transplant for HEH versus other diagnoses. Survival was visualized using Kaplan-Meier curves and compared using log-rank test and multivariable Cox regression. Propensity score matching for recipient age, sex, and MELD was performed, with baseline characteristics and survival compared between groups.Of 111 558 liver transplant recipients identified, 121 (0.1%) underwent transplant for HEH. Donors to HEH recipients were more often living donors. Recipients with HEH were younger, more likely to be female, and had lower BMI. Recipients with HEH had higher albumin, lower bilirubin, lower INR, and lower serum creatinine, as well as lower MELD scores and rates of ascites and encephalopathy. Similar post-transplant survival was observed for recipients with HEH (16.6 [lower 95% CI 14.9] years) and non-HEH diagnoses (13.8 [95% CI 13.6-13.9] years, log-rank p = 0.28), even after adjusting for baseline donor and recipient characteristics (aHR 1.28 [95% CI 0.94-1.74], p = 0.12). The propensity score matched cohort also had similar post-LT survival.This national study represents the largest known report on liver transplant for HEH. The survival of recipients with HEH was similar to other etiologies, supporting the use of liver transplantation (LT) in advanced HEH.

  View details for DOI 10.1111/ctr.70087

  View details for Web of Science ID 001406966900001

  View details for PubMedID 39869081

• Mitral valve repair of papillary muscle rupture using multi-neochord reconstruction. JTCVS techniques Zhou, A. L., Feng, I., Verdi, K. G., Liou, K., Woo, Y. J. 2025; 29: 23-26

  View details for DOI 10.1016/j.xjtc.2024.10.018

  View details for PubMedID 39991279

  View details for PubMedCentralID PMC11845380

• Impact of dual thoracic recovery from circulatory death donors on heart and lung transplant outcomes JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Zhou, A. L., Rizaldi, A. A., Ruck, J. M., Akbar, A. F., Kalra, A., Casillan, A. J., Ha, J. S., Merlo, C. A., Kilic, A., Bush, E. L. 2025; 169 (2): 505-515.e5

  Abstract

  Concomitant heart and lung recovery can result in increased operative complexity, ischemic time, and competition for resources and anatomic territory. Dual thoracic recovery from circulatory death donors may have additional risks that are not fully understood. We investigated the effects of dual heart and lung recovery from circulatory death donors on thoracic transplant outcomes.Using the United Network for Organ Sharing database, we categorized all adult thoracic circulatory death donor transplants from 2019 to 2023 by whether the donor heart, lung, or both (dual donors) were recovered. Heart and lung transplant outcomes were compared between dual recovery donors and heart-only or lung-only donors, respectively, using multivariable analyses.Of the 2513 donors included, 42.9% were heart-only, 45.0% were lung-only, and 12.0% were dual donors. Recipients of dual versus heart-only donors had similar likelihood of post-transplant dialysis (18.9% vs 18.3%, P = .84), likelihood of stroke (2.9% vs 4.7%, P = .34), and 2-year risk of mortality (adjusted hazard ratio, 1.15 [95% CI, 0.90-1.47], P = .26), but lower likelihood of acute rejection (10.2% vs 16.1%, P = .04). Recipients of dual and lung-only donors had similar likelihood of predischarge acute rejection (7.6% vs 8.5%, P = .70), intubation at 72 hours (38.9% vs 45.1%, P = .13), and extracorporeal membrane oxygenation at 72 hours (13.1% vs 18.1%, P = .11), as well as 2-year risk of mortality (adjusted hazard ratio, 1.16 [95% CI, 0.74-1.82], P = .52).Recovering both the heart and lungs from a circulatory death donor does not negatively impact transplant outcomes. Outcomes in this population should continue to be investigated as more data and longer-term follow-up become available.

  View details for DOI 10.1016/j.jtcvs.2024.07.008

  View details for Web of Science ID 001414285200001

  View details for PubMedID 39004267

  View details for PubMedCentralID PMC11729357

• Higher Hospitalization Costs and Fewer Routine Discharges in the Medicaid Expansion Era for Lung Transplant Recipients CLINICAL TRANSPLANTATION Kalra, A., Ruck, J. M., Zhou, A. L., Akbar, A. F., Leng, A., You, B., Casillan, A. J., Ha, J. S., Merlo, C. A., Bush, E. L. 2024; 38 (11): e70017

  Abstract

  In January 2014, states expanded Medicaid access under the Affordable Care Act. We studied the financial implications of this policy on lung transplantation, a costly procedure.Lung transplant (LT) hospitalizations were identified within the National Inpatient Sample (2005-2020). Recipients were categorized as "pre-expansion" (1/2005-12/2013) versus "post-expansion" (1/2014-12/2020) of Medicaid and as being in "expander" versus "non-expander" regions. We calculated difference-in-differences estimates comparing pre- and post-expansion eras in expander versus non-expander regions for inflation-adjusted hospitalization costs and for discharge disposition. We evaluated total hospitalization costs using multivariable generalized linear regression, adjusting for recipient demographics, Charlson Comorbidity Index, single versus double-lung transplant, and extracorporeal membrane oxygenation (ECMO), ex-vivo lung perfusion (EVLP), and mechanical ventilation usage.Of the 29 225 LT recipients identified, 14 085 were pre-expansion and 15 140 were post-expansion. More recipients were insured by Medicaid in expander n = 735 (9%) versus non-expander n = 220, (3%) regions (p = 0.01) post-expansion. Hospitalization costs increased post- versus pre-expansion by $20 948 (95% CI = $8713-$33 183, p < 0.001) more in expander versus non-expander regions even after adjustment for risk factors associated with increased costs. Within expander regions, recipients post- versus pre-expansion were less likely to be discharged routinely (n = 2625, 28% vs. n = 3959, 44%) and more likely to be discharged to care facilities (n = 2045, 22% vs. n = 1045, 12%, p < 0.001).Although Medicaid expansion resulted in greater access to care, it was associated with increased hospitalization costs and fewer routine discharges for LT recipients. Further research is warranted to identify the reasons that underpin the financial sequelae of Medicaid expansion, including changes in access to care for sicker patients.

  View details for DOI 10.1111/ctr.70017

  View details for Web of Science ID 001369313800001

  View details for PubMedID 39529145

• National utilization, trends, and lung transplant outcomes of static versus portable ex vivo lung perfusion platforms JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Zhou, A. L., Ruck, J. M., Casillan, A. J., Larson, E. L., Shou, B. L., Ha, J. S., Shah, P. D., Merlo, C. A., Bush, E. L. 2024; 168 (2): 431-439

  Abstract

  This study compared utilization and outcomes of the 2 widely utilized ex vivo lung perfusion (EVLP) platforms in the United States: a static platform and a portable platform.Adult (age 18 years or older) bilateral lung-only transplants utilizing EVLP between February 28, 2018, and December 31, 2022, in the United Network for Organ Sharing database were included. Predischarge acute rejection, intubation at 72 hours posttransplant, extracorporeal membrane oxygenation at 72 hours posttransplant, primary graft dysfunction grade 3 at 72 hours posttransplant, 30-day mortality, and 1-year mortality were evaluated using multivariable regressions.Overall, 607 (6.3%) lung transplants during the study period used EVLP (51.2% static, 48.8% portable). Static EVLP was primarily utilized in the eastern United States, whereas portable EVLP was primarily utilized in the western United States. Static EVLP donors were more likely to be donation after circulatory death (33.4% vs 26.0%; P = .005), have a >20 pack-year smoking history (13.5% vs 6.5%; P = .005), and be extended criteria donors (92.3% vs 85.0%; P = .013), whereas portable EVLP donors were more likely to be older than age 55 years (14.2% vs 8.0%; P = .02). Transplants utilizing the static and portable platforms had similar risk of acute rejection, intubation at 72 hours, extracorporeal membrane oxygenation at 72 hours, primary graft dysfunction grade 3 at 72 hours, and posttransplant mortality at 30 days and 1 year (all P values > .05).The static and portable platforms had significant differences in donor characteristics and geographic distributions of utilization. Despite this, posttransplant survival was similar between the 2 EVLP platforms.

  View details for DOI 10.1016/j.jtcvs.2023.12.015

  View details for Web of Science ID 001272660800001

  View details for PubMedID 38141853

  View details for PubMedCentralID PMC11192856

• Outcomes following concomitant multiorgan heart transplantation from circulatory death donors: The United States experience JOURNAL OF HEART AND LUNG TRANSPLANTATION Zhou, A. L., Rizaldi, A. A., Akbar, A. F., Ruck, J. M., King, E. A., Kilic, A. 2024; 43 (8): 1252-1262

  Abstract

  Donation after circulatory death (DCD) has reemerged as a method of expanding the donor heart pool. Given the high waitlist mortality of multiorgan heart candidates, we evaluated waitlist outcomes associated with willingness to consider DCD offers and post-transplant outcomes following DCD transplant for these candidates.We identified adult multiorgan heart candidates and recipients between January 1, 2020 and March 31, 2023 nationally. Among candidates that met inclusion criteria, we compared the cumulative incidence of transplant, with waitlist death/deterioration as a competing risk, by willingness to consider DCD offers. Among recipients of DCD versus brain death (DBD) transplants, we compared perioperative outcomes and post-transplant survival.Of 1,802 heart-kidney, 266 heart-liver, and 440 heart-lung candidates, 15.8%, 12.4%, and 31.1%, respectively, were willing to consider DCD offers. On adjusted analysis, willingness to consider DCD offers was associated with higher likelihood of transplant for all multiorgan heart candidates and decreased likelihood of waitlist deterioration for heart-lung candidates. Of 1,100 heart-kidney, 173 heart-liver, and 159 heart-lung recipients, 5.4%, 2.3%, and 2.5%, respectively, received DCD organs. Recipients of DCD and DBD heart-kidney transplants had a similar likelihood of perioperative outcomes and 1-year survival. All other DCD multiorgan heart recipients have survived to the last follow-up.Multiorgan heart candidates who were willing to consider DCD offers had favorable waitlist outcomes, and heart-kidney recipients of DCD transplants had similar post-transplant outcomes to recipients of DBD transplants. We recommend the use of DCD organs to increase the donor pool for these high-risk candidates.

  View details for DOI 10.1016/j.healun.2024.03.013

  View details for Web of Science ID 001270447500001

  View details for PubMedID 38548240

• Outcomes of Heart Transplant Using High Donor Sequence Number Offers JOURNAL OF SURGICAL RESEARCH Zhou, A. L., Daskam, M. L., Ruck, J. M., Akbar, A. F., Larson, E. L., Casillan, A. J., Kilic, A. 2024; 300: 325-335

  Abstract

  Higher donor sequence numbers (DSNs) might spark provider concern about poor donor quality. We evaluated characteristics of high-DSN offers used for transplant and compared outcomes of high- and low-DSN transplants.Adult isolated heart transplants between January 1, 2015, and December 31, 2022, were identified from the organ procurement and transplantation network database and stratified into high (≥42) and low (<42) DSN. Postoperative outcomes, including predischarge complications, hospital length of stay, and survival at 1 and 3 y, were evaluated using multivariable regressions.A total of 21,217 recipients met the inclusion criteria, with 2131 (10.0%) classified as high-DSN. Donor factors associated with greater odds of high-DSN at acceptance included older age, higher creatinine, diabetes, hypertension, and lower left ventricular ejection fraction. Recipients accepting high-DSN offers were older and more likely to be female, of blood type O, and have lower status at transplant. High- and low-DSN transplants had similar likelihood of stroke (3.2% versus 3.5%; P = 0.97), dialysis (12.3% versus 13.5%; P = 0.12), pacemaker implant (2.3% versus 2.1%; P = 0.64), had similar lengths of stay (16 [12-24] versus 16 [12-25] days, P = 0.38), and survival at 1 (91.6% versus 91.6%; aHR 0.85 [0.72-1.02], P = 0.08) and 3 y (84.2% versus 85.1%; aHR 0.91 [0.79-1.05], P = 0.21) post-transplant.High-DSN (≥42) was not an independent risk factor for post-transplant mortality and should not be the sole deterrent to acceptance. Accepting high-DSN organs may increase access to transplantation for lower-status candidates.

  View details for DOI 10.1016/j.jss.2024.05.008

  View details for Web of Science ID 001263460500001

  View details for PubMedID 38838430

  View details for PubMedCentralID PMC11246808

• Normothermic regional perfusion in the United States: A call for improved data JOURNAL OF HEART AND LUNG TRANSPLANTATION Zhou, A. L., Akbar, A. F., Kilic, A. 2024; 43 (7): 1196-1197

  View details for DOI 10.1016/j.healun.2024.03.011

  View details for Web of Science ID 001249237400016

  View details for PubMedID 38521115

• Special Considerations for Advanced Heart Failure Surgeries: Durable Left Ventricular Devices and Heart Transplantation JOURNAL OF CARDIOVASCULAR DEVELOPMENT AND DISEASE Akbar, A. F., Zhou, A. L., Wang, A., Feng, A. S. N., Rizaldi, A. A., Ruck, J. M., Kilic, A. 2024; 11 (4)

  Abstract

  Heart transplantation and durable left ventricular assist devices (LVADs) represent two definitive therapies for end-stage heart failure in the modern era. Despite technological advances, both treatment modalities continue to experience unique risks that impact surgical and perioperative decision-making. Here, we review special populations and factors that impact risk in LVAD and heart transplant surgery and examine critical decisions in the management of these patients. As both heart transplantation and the use of durable LVADs as destination therapy continue to increase, these considerations will be of increasing relevance in managing advanced heart failure and improving outcomes.

  View details for DOI 10.3390/jcdd11040119

  View details for Web of Science ID 001210342300001

  View details for PubMedID 38667737

  View details for PubMedCentralID PMC11050210

• Outcomes of Lung Transplant Candidates Aged ≥ 70 Years During the Lung Allocation Score Era ANNALS OF THORACIC SURGERY Zhou, A. L., Karius, A. K., Ruck, J. M., Shou, B. L., Larson, E. L., Casillan, A. J., Ha, J. S., Shah, P. D., Merlo, C. A., Bush, E. L. 2024; 117 (4): 725-732

  Abstract

  With the increasing age of lung transplant candidates, we studied waitlist and posttransplantation outcomes of candidates ≥70 years during the Lung Allocation Score era.Adult lung transplant candidates from 2005 to 2020 in the United Network for Organ Sharing database were included and stratified on the basis of age at listing into 18 to 59 years old, 60 to 69 years old, and ≥70 years old. Baseline characteristics, waitlist outcomes, and posttransplantation outcomes were assessed.A total of 37,623 candidates were included (52.3% aged 18-59 years, 40.6% aged 60-69 years, 7.1% aged ≥70 years). Candidates ≥70 years were more likely than younger candidates to receive a transplant (81.9% vs 72.7% [aged 60-69 years] vs 61.6% [aged 18-59 years]) and less likely to die or to deteriorate on the waitlist within 1 year (9.1% vs 10.1% [aged 60-69 years] vs 12.2% [aged 18-59 years]; P < .001). Donors for older recipients were more likely to be extended criteria (75.7% vs 70.1% [aged 60-69 years] vs 65.7% [aged 18-59 years]; P < .001). Recipients ≥70 years were found to have lower rates of acute rejection (6.7% vs 7.4% [aged 60-69 years] vs 9.2% [aged 18-59 years]; P < .001) and prolonged intubation (21.7% vs 27.4% [aged 60-69 years] vs 34.5% [aged 18-59 years]; P < .001). Recipients aged ≥70 years had increased 1-year (adjusted hazard ratio [aHR], 1.19 [95% CI, 1.06-1.33]; P < .001), 3-year (aHR, 1.28 [95% CI, 1.18-1.39]; P < .001), and 5-year mortality (aHR, 1.29 [95% CI, 1.21-1.38]; P < .001) compared with recipients aged 60 to 69 years.Candidates ≥70 years had favorable waitlist and perioperative outcomes despite increased use of extended criteria donors. Careful selection of candidates and postoperative surveillance may improve posttransplantation survival in this population.

  View details for DOI 10.1016/j.athoracsur.2023.04.046

  View details for Web of Science ID 001217541800001

  View details for PubMedID 37271446

  View details for PubMedCentralID PMC10693648

• Outcomes of Recipients Aged 65 Years and Older Bridged to Lung Transplant With Extracorporeal Membrane Oxygenation ASAIO JOURNAL Zhou, A. L., Jenkins, R. T., Ruck, J. M., Shou, B. L., Larson, E. L., Casillan, A. J., Ha, J. S., Merlo, C. A., Bush, E. L. 2024; 70 (3): 230-238

  Abstract

  Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplant (BTT) has been used for critically ill candidates with excellent outcomes, but data on this strategy in older recipients remain limited. We compared outcomes of no BTT, mechanical ventilation (MV)-only BTT, and ECMO BTT in recipients of greater than or equal to 65 years. Lung-only recipients of greater than or equal to 65 years in the United Network for Organ Sharing database between 2008 and 2022 were included and stratified by bridging strategy. Of the 9,936 transplants included, 226 (2.3%) were MV-only BTT and 159 (1.6%) were ECMO BTT. Extracorporeal membrane oxygenation BTT recipients were more likely to have restrictive disease pathology, had higher median lung allocation score, and spent fewer days on the waitlist (all p < 0.001). Compared to no-BTT recipients, ECMO BTT recipients were more likely to be intubated or on ECMO at 72 hours posttransplant and had longer hospital lengths of stay (all p < 0.001). Extracorporeal membrane oxygenation BTT recipients had increased risk of 3 years mortality compared to both no-BTT (adjusted hazard ratio [aHR] = 1.48 [95% confidence interval {CI}: 1.14-1.91], p = 0.003) and MV-only recipients (aHR = 1.50 [95% CI: 1.08-2.07], p = 0.02). Overall, we found that ECMO BTT in older recipients is associated with inferior posttransplant outcomes compared to MV-only or no BTT, but over half of recipients remained alive at 3 years posttransplant.

  View details for DOI 10.1097/MAT.0000000000002092

  View details for Web of Science ID 001171818000004

  View details for PubMedID 37939695

  View details for PubMedCentralID PMC10922625

• Current status and future potential of ex vivo lung perfusion in clinical lung transplantation ARTIFICIAL ORGANS Zhou, A. L. L., Larson, E. L. L., Ruck, J. M. M., Ha, J. S. S., Casillan, A. J. J., Bush, E. L. L. 2023; 47 (11): 1700-1709

  Abstract

  Lung transplantation is accepted as a well-established and effective treatment for patients with end-stage lung disease. While the number of candidates added to the waitlist continues to rise, the number of transplants performed remains limited by the number of suitable organ donors. Ex vivo lung perfusion (EVLP) emerged as a method of addressing the organ shortage by allowing the evaluation and potential reconditioning of marginal donor lungs or minimizing risks of prolonged ischemic time due to logistical challenges. The currently available FDA-approved EVLP systems have demonstrated excellent outcomes in clinical trials, and retrospective studies have demonstrated similar post-transplant survival between recipients who received marginal donor lungs perfused using EVLP and recipients who received standard criteria lungs stored using conventional methods. Despite this, widespread utilization has plateaued in the last few years, likely due to the significant costs associated with initiating EVLP programs. Centralized, dedicated EVLP perfusion centers are currently being investigated as a potential method of further expanding utilization of this technology. In the preclinical setting, potential applications of EVLP that are currently being studied include prolongation of organ preservation, reconditioning of unsuitable lungs, and further enhancement of already suitable lungs. As adoption of EVLP technology becomes more widespread, we may begin to see future implementation of these potential applications into the clinical setting.

  View details for DOI 10.1111/aor.14607

  View details for Web of Science ID 001031714300001

  View details for PubMedID 37455548

• Prenatal Sonography in Suspected Proximal Gastrointestinal Obstructions: Diagnostic Accuracy and Neonatal Outcomes JOURNAL OF PEDIATRIC SURGERY Engwall-Gill, A. J., Zhou, A. L., Penikis, A. B., Sferra, S. R., Jelin, A. C., Blakemore, K. J., Kunisaki, S. M. 2023; 58 (6): 1090-1094

  Abstract

  The purpose of this study was to assess diagnostic accuracy and neonatal outcomes in fetuses with a suspected proximal gastrointestinal obstruction (GIO).After IRB approval, a retrospective chart review was conducted on prenatally suspected and/or postnatally confirmed cases of proximal GIO at a tertiary care facility (2012-2022). Maternal-fetal records were queried for presence of a double bubble ± polyhydramnios, and neonatal outcomes were assessed to calculate the diagnostic accuracy of fetal sonography.Among 56 confirmed cases, the median birthweight and gestational age at birth were 2550 g [interquartile range (IQR) 2028-3012] and 37 weeks (IQR 34-38), respectively. There was one (2%) false-positive and three (6%) false-negatives by ultrasound. Double bubble had a sensitivity, specificity, positive predictive value, and negative predictive value for proximal GIO of 85%, 98%, 98%, and 83%, respectively. Pathologies included 49 (88%) with duodenal obstruction/annular pancreas, three (5%) with malrotation, and three (5%) with jejunal atresia. The median postoperative length of stay was 27 days (IQR 19-42). Cardiac anomalies were associated with significantly higher complications (45% vs 17%, p = 0.030).In this contemporary series, fetal sonography has high diagnostic accuracy for detecting proximal gastrointestinal obstruction. These data are informative for pediatric surgeons in prenatal counseling and preoperative discussions with families.Diagnostic Study, Level III.

  View details for DOI 10.1016/j.jpedsurg.2023.02.029

  View details for Web of Science ID 001001725100001

  View details for PubMedID 36907770

  View details for PubMedCentralID PMC10866136

• Early United States experience with lung donation after circulatory death using thoracoabdominal normothermic regional perfusion JOURNAL OF HEART AND LUNG TRANSPLANTATION Zhou, A. L., Ruck, J. M., Casillan, A. J., Larson, E. L., Shou, B. L., Karius, A. K., Ha, J. S., Shah, P. D., Merlo, C. A., Bush, E. L. 2023; 42 (6): 693-696

  Abstract

  Thoracoabdominal normothermic regional perfusion (TA-NRP) has recently begun being utilized in the United States for recovery of cardiothoracic allografts from some donors after circulatory death (DCD), but data on lungs recovered in this method is limited to case reports. We conducted a national retrospective review of lung transplants from DCD donors recovered using TA-NRP. Of the 434 total DCD lung transplants performed between January 2020 and March 2022, 17 were recovered using TA-NRP. Compared to direct recovery DCD transplants, recipients of TA-NRP DCD transplants had lower likelihood of ventilation >48 hours (23.5% vs 51.3%, p = 0.027) and similar likelihood of predischarge acute rejection, requirement for extracorporeal membrane oxygenation at 72 hours, hospital lengths of stay, and survival at 30, 60, and 90 days post-transplant. These early data suggest that DCD lung recovery using TA-NRP might be a safe way to further expand the donor pool and warrant further study.

  View details for DOI 10.1016/j.healun.2023.03.001

  View details for Web of Science ID 001002265200001

  View details for PubMedID 36990867

  View details for PubMedCentralID PMC10192114

• The impact of a statewide payment reform on transcatheter aortic valve replacement (TAVR) utilization and readmissions CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS Yesantharao, P. S., Etchill, E. W., Zhou, A. L., Ong, C., Metkus, T. S., Canner, J. K., Alejo, D. E., Aliu, O., Czarny, M. J., Hasan, R. K., Resar, J. R., Schena, S. 2023; 101 (7): 1193-1202

  Abstract

  Transcatheter aortic valve replacement (TAVR) is an increasingly used but relatively expensive procedure with substantial associated readmission rates. It is unknown how cost-constrictive payment reform measures, such as Maryland's All Payer Model, impact TAVR utilization given its relative expense. This study investigated the impact of Maryland's All Payer Model on TAVR utilization and readmissions among Maryland Medicare beneficiaries.This was a quasi-experimental investigation of Maryland Medicare patients undergoing TAVR between 2012 and 2018. New Jersey data were used for comparison. Longitudinal interrupted time series analyses were used to study TAVR utilization and difference-in-differences analyses were used to investigate post-TAVR readmissions.During the first year of payment reform (2014), TAVR utilization among Maryland Medicare beneficiaries dropped by 8% (95% confidence interval [CI]: -9.2% to -7.1%; p < 0.001), with no concomitant change in TAVR utilization in New Jersey (0.2%, 95% CI: 0%-1%, p = 0.09). Longitudinally, however, the All Payer Model did not impact TAVR utilization in Maryland compared to New Jersey. Difference-in-differences analyses demonstrated that implementation of the All Payer Model was not associated with significantly greater declines in 30-day post-TAVR readmissions in Maryland versus New Jersey (-2.1%; 95% CI: -5.2% to 0.9%; p =0.1).Maryland's All Payer Model resulted in an immediate decline in TAVR utilization, likely a result of hospitals adjusting to global budgeting. However, beyond this transition period, this cost-constrictive reform measure did not limit Maryland TAVR utilization. In addition, the All Payer Model did not reduce post-TAVR 30-day readmissions. These findings may help inform expansion of globally budgeted healthcare payment structures.

  View details for DOI 10.1002/ccd.30670

  View details for Web of Science ID 000977147700001

  View details for PubMedID 37102376

• Trends in use and three-year outcomes of hepatitis C virus-viremic donor lung transplants for hepatitis C virus- seronegative recipients JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Ruck, J. M., Zeiser, L. B., Zhou, A. L., Chidi, A. P., Winchester, S. L., Durand, C. M., Ha, J. S., Shah, P. D., Massie, A. B., Segev, D. L., Merlo, C. A., Bush, E. L. 2023; 165 (4): 1587-1595.e2

  Abstract

  The feasibility and 6-month outcome safety of lung transplants (LTs) from hepatitis C virus (HCV)-viremic donors for HCV-seronegative recipients (R-) were established in 2019, but longer-term safety and uptake of this practice nationally remain unknown.We identified HCV-seronegative LT recipients (R-) 2015-2020 using the Scientific Registry of Transplant Recipients. We classified donors as seronegative (D-) or viremic (D+). We used χ2 testing, rank-sum testing, and Cox regression to compare posttransplant outcomes between HCV D+/R- and D-/R- LT recipients.HCV D+/R- LT increased from 2 to 97/year; centers performing HCV D+/R- LT increased from 1 to 25. HCV D+/R- versus HCV D-/R- LT recipients had more obstructive disease (35.7% vs 23.3%, P < .001), lower lung allocation score (36.5 vs 41.1, P < .001), and longer waitlist time (P = .002). HCV D+/R- LT had similar risk of acute rejection (adjusted odds ratio [aOR], 0.87; P = .58), extracorporeal membranous oxygenation (aOR, 1.94; P = .10), and tracheostomy (aOR, 0.42; P = .16); similar median hospital stay (P = .07); and lower risk of ventilator > 48 hours (aOR, 0.68; P = .006). Adjusting for donor, recipient, and transplant characteristics, risk of all-cause graft failure and mortality were similar at 30 days, 1 year, and 3 years for HCV D+/R- versus HCV D-/R- LT (all P > .1), as well as for high- (≥20/year) versus low-volume LT centers and high- (≥5/year) versus low-volume HCV D+/R- LT centers (all P > .5).HCV D+/R- and HCV D-/R- LT have similar outcomes at 3 years posttransplant. These results underscore the safety of HCV D+/R- LT and the potential benefit of expanding this practice further.

  View details for DOI 10.1016/j.jtcvs.2022.08.019

  View details for Web of Science ID 000951640600001

  View details for PubMedID 36207160

  View details for PubMedCentralID PMC9989038

• Arterial Carbon Dioxide and Acute Brain Injury in Venoarterial Extracorporeal Membrane Oxygenation ASAIO JOURNAL Shou, B. L. L., Ong, C., Zhou, A. L., Al-Kawaz, M. N. N., Etchill, E., Giuliano, K., Dong, J., Bush, E., Kim, B., Choi, C., Whitman, G., Cho, S. 2022; 68 (12): 1501-1507

  Abstract

  Acute brain injury (ABI) occurs frequently in patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO). We examined the association between peri-cannulation arterial carbon dioxide tension (PaCO 2 ) and ABI with granular blood gas data. We retrospectively analyzed adult patients who underwent VA-ECMO at a tertiary care center with standardized neuromonitoring. Pre- and post-cannulation PaCO 2 were defined as the mean of all PaCO 2 values in the 12 hours before and after cannulation, respectively. Peri-cannulation PaCO 2 drop (∆PaCO 2 ) equaled pre- minus post-cannulation PaCO 2 . ABI included intracranial hemorrhage (ICH), ischemic stroke, hypoxic-ischemic brain injury, cerebral edema, seizure, and brain death. Univariable logistic regression analysis was performed for the presence of ABI. Out of 129 VA-ECMO patients (median age = 60, 63% male), 43 (33%) patients experienced ABI. Patients had a median of 11 (interquartile range: 8-14) peri-cannulation PaCO 2 values. Comparing patients with and without ABI, pre-cannulation (39 vs. 42 mm Hg; p = 0.38) and post-cannulation (37 vs. 36 mm Hg; p = 0.82) PaCO 2 were not different. However, higher pre-cannulation PaCO 2 (odds ratio [OR] = 2.10; 95% confidence interval [CI] = 1.10-4.00; p = 0.02) and larger ∆PaCO 2 (OR = 2.69; 95% CI = 1.18-6.13; p = 0.02) were associated with ICH. In conclusion, in a cohort with granular arterial blood gas (ABG) data and a standardized neuromonitoring protocol, higher pre-cannulation PaCO 2 and larger ∆PaCO 2 were associated with increased prevalence of ICH.

  View details for DOI 10.1097/MAT.0000000000001699

  View details for Web of Science ID 000894502700019

  View details for PubMedID 35671442

  View details for PubMedCentralID PMC9477972

• Trends and three-year outcomes of hepatitis C virus- viremic donor heart transplant for hepatitis C virus-seronegative recipients JTCVS OPEN Ruck, J. M., Zhou, A. L., Zeiser, L. B., Alejo, D., Durand, C. M., Massie, A. B., Segev, D. L., Bush, E. L., Kilic, A. 2022; 12: 269-279

  Abstract

  Heart transplants (HTs) from hepatitis C virus (HCV)-viremic donors to HCV-seronegative recipients (HCV D+/R-) have good 6-month outcomes, but practice uptake and long-term outcomes overall and among candidates on mechanical circulatory support (MCS) have yet to be established.Using the Scientific Registry of Transplant Recipients, we identified US adult HCV-seronegative HT recipients (R-) from 2015 to 2021. We classified donors as HCV-seronegative (D-) or HCV-viremic (D+). We used multivariable regression to compare post-HT extracorporeal membranous oxygenation, dialysis, pacemaker, acute rejection, and risk of post-HT mortality between HCV D+/R- and HCV D-/R-. Models were adjusted for donor, recipient, and transplant characteristics and center HT volume. We performed subgroup analyses of recipients bridged with MCS.From 2015 to 2021, the number of HCV D+/R- HT increased from 1 to 181 and the number of centers performing HCV D+/R- HT increased from 1 to 60. Compared with HCV D-/R- recipients, HCV D+/R- versus D-/R- recipients overall and among patients bridged with MCS had similar odds of post-HT extracorporeal membranous oxygenation, dialysis, pacemaker, and acute rejection; and mortality risk at 30 days, 1 year, and 3 years (all P > .05). High center HT volume but not HCV D+/R- volume (<5 vs >5 in any year) was associated with lower mortality for HCV D+/R- HT.HCV D+/R- and D-/R- HT have similar outcomes at 3 years' posttransplant. These results underscore the opportunity provided by HCV D+/R- HT, including among the growing population bridged with MCS, and the potential benefit of further expanding use of HCV+ allografts.

  View details for DOI 10.1016/j.xjon.2022.10.007

  View details for Web of Science ID 001318554000025

  View details for PubMedID 36590744

  View details for PubMedCentralID PMC9801334

• Outcomes after heart transplantation in patients who have undergone a bridge-to-bridge strategy JTCVS OPEN Zhou, A. L., Etchill, E. W., Shou, B. L., Whitbread, J. J., Barbur, I., Giuliano, K. A., Kilic, A. 2022; 12: 255-268

  Abstract

  We compared posttransplant outcomes between patients bridged from temporary mechanical circulatory support to durable left ventricular assist device before transplant (bridge-to-bridge [BTB] strategy) and patients bridged from temporary mechanical circulatory support directly to transplant (bridge-to-transplant [BTT] strategy).We identified adult heart transplant recipients in the Organ Procurement and Transplantation Network database between 2005 and 2020 who were supported with extracorporeal membrane oxygenation, intra-aortic balloon pump, or temporary ventricular assist device as a BTB or BTT strategy. Kaplan-Meier survival analysis and Cox regressions were used to assess 1-year, 5-year, and 10-year survival. Posttransplant length of stay and complications were compared as secondary outcomes.In total, 201 extracorporeal membrane oxygenation (61 BTB, 140 BTT), 1385 intra-aortic balloon pump (460 BTB, 925 BTT), and 234 temporary ventricular assist device (75 BTB, 159 BTT) patients were identified. For patients supported with extracorporeal membrane oxygenation, intra-aortic balloon pump, or temporary ventricular assist device, there were no differences in survival between BTB and BTT at 1 and 5 years posttransplant, as well as 10 years posttransplant even after adjusting for baseline characteristics. The extracorporeal membrane oxygenation BTB group had greater rates of acute rejection (32.8% vs 13.6%; P = .002) and lower rates of dialysis (1.6% vs 21.4%; P < .001). For intra-aortic balloon pump and temporary ventricular assist device patients, there were no differences in posttransplant length of stay, acute rejection, airway compromise, stroke, dialysis, or pacemaker insertion between BTB and BTT recipients.BTB patients have similar short- and midterm posttransplant survival as BTT patients. Future studies should continue to investigate the tradeoff between prolonged temporary mechanical circulatory support versus transitioning to durable mechanical circulatory support.

  View details for DOI 10.1016/j.xjon.2022.08.011

  View details for Web of Science ID 001318554000024

  View details for PubMedID 36590736

  View details for PubMedCentralID PMC9801290

• Growth Differentiation Factor 15: A Novel Growth Biomarker for Children With Congenital Heart Disease WORLD JOURNAL FOR PEDIATRIC AND CONGENITAL HEART SURGERY Paneitz, D. C., Zhou, A., Yanek, L., Golla, S., Avula, S., Kannankeril, P. J., Everett, A. D., Mettler, B. A., Sen, D. 2022; 13 (6): 745-751

  Abstract

  Failure to thrive (FTT), defined as weight or height less than the lowest 2.5 percentile for age, is prevalent in up to 66% of children with congenital heart disease (CHD). Risk stratification methods to identify those who would benefit from early intervention are currently lacking. We aimed to identify a novel growth biomarker to aid clinical decision-making in children with CHD.This is a cross-sectional study of patients 2 months to 10 years of age with any CHD undergoing cardiac surgery. Preoperative weight-for-age Z scores (WAZ) and height-for-age Z scores (HAZ) were calculated and assessed for association with preoperative plasma biomarkers: growth differentiation factor 15 (GDF-15), fibroblast growth factor 21, leptin, prealbumin, and C-reactive protein (CRP).Of the 238 patients included, approximately 70% of patients had WAZ/HAZ < 0 and 34% had FTT. There was a moderate correlation between GDF-15 and WAZ/HAZ. When stratified by age, the correlation of GDF-15 to WAZ and HAZ was strongest in children under 2 years of age and persisted in the setting of inflammation (CRP > 0.5 mg/dL). Diagnoses commonly associated with congestive heart failure had high proportions of FTT and median GDF-15 levels. Prealbumin was not correlated with WAZ or HAZ.GDF-15 represents an important growth biomarker in children with CHD, especially those under 2 years of age who have diagnoses commonly associated with CHF. Our data do not support prealbumin as a long-term growth biomarker.

  View details for DOI 10.1177/21501351221118080

  View details for Web of Science ID 000874065100009

  View details for PubMedID 36300261

  View details for PubMedCentralID PMC10947752

• Pre-operative Machine Learning for Heart Transplant Patients Bridged with Temporary Mechanical Circulatory Support JOURNAL OF CARDIOVASCULAR DEVELOPMENT AND DISEASE Shou, B. L., Chatterjee, D., Russel, J. W., Zhou, A. L., Florissi, I. S., Lewis, T., Verma, A., Benharash, P., Choi, C. 2022; 9 (9)

  Abstract

  Background: Existing prediction models for post-transplant mortality in patients bridged to heart transplantation with temporary mechanical circulatory support (tMCS) perform poorly. A more reliable model would allow clinicians to provide better pre-operative risk assessment and develop more targeted therapies for high-risk patients. Methods: We identified adult patients in the United Network for Organ Sharing database undergoing isolated heart transplantation between 01/2009 and 12/2017 who were supported with tMCS at the time of transplant. We constructed a machine learning model using extreme gradient boosting (XGBoost) with a 70:30 train:test split to predict 1-year post-operative mortality. All pre-transplant variables available in the UNOS database were included to train the model. Shapley Additive Explanations was used to identify and interpret the most important features for XGBoost predictions. Results: A total of 1584 patients were included, with a median age of 56 (interquartile range: 46-62) and 74% male. Actual 1-year mortality was 12.1%. Out of 498 available variables, 43 were selected for the final model. The area under the receiver operator characteristics curve (AUC) for the XGBoost model was 0.71 (95% CI: 0.62-0.78). The most important variables predictive of 1-year mortality included recipient functional status, age, pulmonary capillary wedge pressure (PCWP), cardiac output, ECMO usage, and serum creatinine. Conclusions: An interpretable machine learning model trained on a large clinical database demonstrated good performance in predicting 1-year mortality for patients bridged to heart transplantation with tMCS. Machine learning may be used to enhance clinician judgement in the care of markedly high-risk transplant recipients.

  View details for DOI 10.3390/jcdd9090311

  View details for Web of Science ID 000856397100001

  View details for PubMedID 36135456

  View details for PubMedCentralID PMC9500687

• Massive left atrial thrombus evades multimodality imaging as a myxoma in a bicaval heart transplant recipient JOURNAL OF CARDIAC SURGERY Shou, B. L., Halub, M. E., Zhou, A. L., Thompkins, B. A., Choi, C. W. 2022; 37 (9): 2884-2887

  Abstract

  Intracardiac masses are an extremely rare and poorly described complication following a bicaval heart transplantation. We describe the case of an asymptomatic 62-year-old male with a large left atrial mass found incidentally on transthoracic echocardiography 6 years post-transplant. A battery of additional imaging tests was ordered including transesophageal echocardiography, 18 F-fluorodeoxyglucose positron emission tomography/computed tomography, and T1 and T2 magnetic resonance imaging. Although imaging biomarkers were generally nonspecific, the mass was most consistent with a cardiac myxoma. However, intraoperative findings confirmed by pathology revealed a massive organizing thrombus. The patient had an uneventful recovery after surgical removal of the mass. Our case highlights a very rare phenomenon in heart transplant recipients which remains a unique diagnostic challenge even with current advances in imaging.

  View details for DOI 10.1111/jocs.16708

  View details for Web of Science ID 000820620200001

  View details for PubMedID 35789119

• UNOS listing status-related changes in mechanical circulatory support utilization and outcomes in adult congenital heart disease patients JOURNAL OF HEART AND LUNG TRANSPLANTATION Zhou, A. L., Menachem, J. N., Danford, D. A., Kutty, S., Cedars, A. M. 2022; 41 (7): 889-895

  Abstract

  The aim of this study was to investigate the impact of the new United Network for Organ Sharing (UNOS) listing criteria on mechanical circulatory support (MCS) utilization and outcomes in adult congenital heart disease (ACHD) patients.We identified all ACHD and non-ACHD heart transplant candidates in the Scientific Registry of Transplant Recipients database listed during the 590 days prior to (historical cohort) or following (recent cohort) the UNOS allocation revision on October 18, 2018. Patients were grouped based on whether they received central temporary MCS (tMCS), peripheral tMCS, durable MCS, or no MCS.A total of 535 ACHD (242 historical, 293 recent) and 12,188 non-ACHD (6,258 historical, 5,930 recent) patients were included in our study. For ACHD patients, we found no differences in the historical versus recent cohort in utilization of central tMCS (3.31% vs 3.07%, p = .88) or durable MCS (3.31% vs 3.41%, p = .95), whereas the rate of peripheral tMCS increased (2.07% historical vs 6.83% recent, p = .009). Across both cohorts, ACHD patients supported with peripheral tMCS had shorter time-to-transplant than non-supported patients (25.7 vs 121.7 days, p = .002). ACHD patients supported with central tMCS had greater rates of post-transplant mortality relative to other ACHD patients (40.0% vs 12.6%, p = .006), while those supported with durable or peripheral temporary MCS had no differences in waitlist or post-transplant mortality compared to non-supported ACHD patients.The 2018 UNOS allocation changes increased utilization of peripheral temporary MCS in ACHD patients, decreasing waitlist time without impact on post-transplant outcomes.

  View details for DOI 10.1016/j.healun.2022.03.001

  View details for Web of Science ID 000861338000009

  View details for PubMedID 35397877

• Caseous necrosis of the mitral annulus masquerading as an intracardiac mass. Global cardiology science & practice Shou, B. L., Halub, M. E., Zhou, A. L., Lawton, J. S. 2022; 2022 (1-2): e202201

  Abstract

  Caseous necrosis of the mitral annulus is a rare condition which typically involves the posterior leaflet or annulus. We report the case of a 71-year-old female with extensive comorbidities, presenting with dyspnea and angina, who had an incidental echocardiographic finding of a mass on or near the mitral valve. The mass increased in size over the course of three years and was associated with severe mitral regurgitation. The mass was initially thought to be a myxoma, however, surgical exploration revealed caseous necrosis of the posterior mitral annulus. Following removal of the necrotic tissue and distorted mitral leaflet, a bioprosthetic mitral valve was implanted and the patient recovered uneventfully.

  View details for DOI 10.21542/gcsp.2022.1

  View details for PubMedID 36339670

• Massive primary cardiac synovial sarcoma of the left atrium: a case report JOURNAL OF CARDIOTHORACIC SURGERY Zhou, A. L., Halub, M. E., Gross, J. M., Shou, B. L., Kilic, A. 2022; 17 (1): 76

  Abstract

  Synovial sarcomas are tumors typically located in the extremities and characterized by a t(X;18)(p11.2;q11.2) chromosomal translocation. With only around 100 cases reported in the literature, cardiac synovial sarcomas are extremely rare.We describe a case of a 59-year-old male who presented to his primary care physician with chest pain, palpitations, and dyspnea and was diagnosed with atrial flutter. Following atrial ablation, a transthoracic echocardiogram incidentally revealed a 5.5 × 5.0 cm heterogeneous mass. Further workup found a heterogeneous mass with mild fluorodeoxyglucose uptake that was abutting the left atrium, left ventricle, and left pulmonary veins. The tumor was resected and confirmed to be a monophasic synovial sarcoma with a SS18-SSX gene fusion. Four months post-operative, the patient had recovered well from surgery. He is currently undergoing concurrent radiation and chemotherapy.Due to the rarity of this tumor, guidelines on diagnosis and treatment come only from case reports. Our case describes a primary cardiac synovial sarcoma arising from the left atrium in the atrioventricular groove in which diagnosis of atrial flutter preceded detection of the mass.

  View details for DOI 10.1186/s13019-022-01822-w

  View details for Web of Science ID 000782602500002

  View details for PubMedID 35422025

  View details for PubMedCentralID PMC9009006

• Pulmonary artery transection for resection of a middle mediastinal paraganglioma CLINICAL CASE REPORTS Zhou, A. L., Halub, M. E., Lotfalla, M., Shou, B. L., Kilic, A. 2022; 10 (4): e05600

  Abstract

  We report the case of a 65-year-old male patient who presented with chest pain and was found to have a mediastinal paraganglioma between the left atrium and main pulmonary artery. This is the first reported case of a mediastinal paraganglioma resection utilization transection of the main pulmonary artery.

  View details for DOI 10.1002/ccr3.5600

  View details for Web of Science ID 000779382200001

  View details for PubMedID 35425604

  View details for PubMedCentralID PMC8991763

• Bridge to transplantation from mechanical circulatory support: a narrative review JOURNAL OF THORACIC DISEASE Zhou, A. L., Etchill, E. W., Giuliano, K. A., Shou, B. L., Sharma, K., Choi, C. W., Kilic, A. 2021; 13 (12): 6911-6923

  Abstract

  To highlight recent developments in the utilization of mechanical circulatory support (MCS) devices as bridge-to-transplant strategies and to discuss trends in MCS use following the changes to the United Network for Organ Sharing (UNOS) heart allocation system.MCS devices have played an increasingly important role in the treatment of heart failure patients. Over the past several years, technological advancements have led to new developments in MCS devices and expanding indications for MCS use. In October of 2018, the UNOS heart allocation policy was revised to prioritize higher-urgency patients, including those supported with temporary MCS devices. Since then, changes in trends of MCS utilization have been observed.Articles from the PubMed database regarding the use of MCS devices as bridge-to-transplant strategies were reviewed.Over the past decade, utilization of temporary MCS devices, which include the intra-aortic balloon pump (IABP), percutaneous ventricular assist devices (pVADs), and extracorporeal membrane oxygenation (ECMO), has become increasingly common. Recent advancements in MCS include the development of pVADs that can fully unload the left ventricle (LV) as well as devices designed to provide right-sided support. Technological advancements in durable left ventricular assist devices (LVADs) have also led to improved outcomes both on the device and following heart transplantation. Following the 2018 UNOS heart allocation policy revision, the utilization of temporary MCS in advanced heart failure patients has further increased and the proportion of patients bridged directly from a temporary MCS device has exponentially risen. However, following the start of the COVID-19 pandemic, the trends have reversed, with a decrease in the percentage of patients bridged from a temporary MCS device. As long-term data following the allocation policy revision becomes available, future studies should investigate how trends in MCS use for patients with advanced heart failure continue to evolve.

  View details for DOI 10.21037/jtd-21-832

  View details for Web of Science ID 000719384600001

  View details for PubMedID 35070375

  View details for PubMedCentralID PMC8743412