March 5, 2019 e1 WRITING GROUP MEMBERS Emelia J. Benjamin, MD, ScM, FAHA, Chair Paul Muntner, PhD, MHS, FAHA, Vice Chair Alvaro Alonso, MD, PhD, FAHA Marcio S. Bittencourt, MD, PhD, MPH Clifton W. Callaway, MD, FAHA April P. Carson, PhD, MSPH, FAHA Alanna M. Chamberlain, PhD Alexander R. Chang, MD, MS Susan Cheng, MD, MMSc, MPH, FAHA Sandeep R. Das, MD, MPH, MBA, FAHA Francesca N. Delling, MD, MPH Luc Djousse, MD, ScD, MPH Mitchell S.V. Elkind, MD, MS, FAHA Jane F. Ferguson, PhD, FAHA Myriam Fornage, PhD, FAHA Lori Chaffin Jordan, MD, PhD, FAHA Sadiya S. Khan, MD, MSc Brett M. Kissela, MD, MS Kristen L. Knutson, PhD Tak W. Kwan, MD, FAHA Daniel T. Lackland, DrPH, FAHA Tené T. Lewis, PhD Judith H. Lichtman, PhD, MPH, FAHA Chris T. Longenecker, MD Matthew Shane Loop, PhD Pamela L. Lutsey, PhD, MPH, FAHA Seth S. Martin, MD, MHS, FAHA Kunihiro Matsushita, MD, PhD, FAHA Andrew E. Moran, MD, MPH, FAHA Michael E. Mussolino, PhD, FAHA Martin O’Flaherty, MD, MSc, PhD Ambarish Pandey, MD, MSCS Amanda M. Perak, MD, MS Wayne D. Rosamond, PhD, MS, FAHA Gregory A. Roth, MD, MPH, FAHA Uchechukwu K.A. Sampson, MD, MBA, MPH, FAHA Gary M. Satou, MD, FAHA Emily B. Schroeder, MD, PhD, FAHA Svati H. Shah, MD, MHS, FAHA Nicole L. Spartano, PhD Andrew Stokes, PhD David L. Tirschwell, MD, MS, MSc, FAHA Connie W. Tsao, MD, MPH, Vice Chair Elect Mintu P. Turakhia, MD, MAS, FAHA Lisa B. VanWagner, MD, MSc, FAST John T. Wilkins, MD, MS, FAHA Sally S. Wong, PhD, RD, CDN, FAHA Salim S. Virani, MD, PhD, FAHA, Chair Elect On behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee

Heart Disease and Stroke Statistics—2019 Update: A Report From the American Heart Association

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/pdf/acc-aha-2005-guideline-update-for-the-diagnosis-and-4hik65ngbe.pdf

ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure).

Mariell Jessup, MD, FACC, FAHA, Chair [*][1]

William T. Abraham, MD, FACC, FAHA[†][2]

Donald E. Casey, MD, MPH, MBA[‡][3]

Arthur M. Feldman, MD, PhD, FACC, FAHA[§][4]

Gary S. Francis, MD, FACC, FAHA[§][4]

Theodore G. Ganiats, MD[∥][5]

Marvin A. Konstam, MD, FACC[¶][6]

Donna M.

/pdf/2009-focused-update-incorporated-into-the-acc-aha-2005-3z9lhvyqwq.pdf

2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: Developed in Collaboration With the International Society for Heart and Lung Transplantation

During the past decade, catheter ablation of atrial fibrillation (AF) has evolved rapidly from an investigational procedure to its current status as a commonly performed ablation procedure in many major hospitals throughout the world. Surgical ablation of AF, using either standard or minimally invasive techniques, is also performed in many major hospitals throughout the world.

In 2007, an initial Consensus Statement on Catheter and Surgical AF Ablation was developed as a joint effort of the Heart Rhythm Society, the European Heart Rhythm Association, and the European Cardiac Arrhythmia Society.1 The 2007 document was also developed in collaboration with the Society of Thoracic Surgeons and the American College of Cardiology. Since the publication of the 2007 document, there has been much learned about AF ablation, and the indications for these procedures have changed. Therefore the purpose of this 2012 Consensus Statement is to provide a state-of-the-art review of the field of catheter and surgical ablation of AF and to report the findings of a Task Force, convened by the Heart Rhythm Society, the European Heart Rhythm Association, and the European Cardiac Arrhythmia Society and charged with defining the indications, techniques, and outcomes of this procedure. Included within this document are recommendations pertinent to the design of clinical trials in the field of AF ablation, including definitions relevant to this topic.

This statement summarizes the opinion of the Task Force members based on an extensive literature review as well as their own experience. It is directed to all health care professionals who are involved in the care of patients with AF, particularly those who are undergoing, or are being considered for, catheter or surgical ablation procedures for AF. This statement is not intended to recommend or promote catheter ablation of AF. Rather the ultimate judgment regarding care of a particular patient …

2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: Recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design

Commentary: In a disappointing outcome, much can be learned

Organ donation is a precious gift and for candidates awaiting trans‐ plant, a very limited resource, particularly for children with severe heart failure. The pediatric heart transplant waitlist is rapidly grow‐ ing, and it has increased by 150% in the past decade.1 The responsi‐ bility is on us as a community to carefully utilize this limited resource to benefit the growing number of sick children awaiting transplanta‐ tion. We only utilize approximately 30% of all available donors for heart transplantation.1 Why is that? Our community has persisted to allow great variability in who gets listed, who stays listed, and which organs to accept. These criteria vary greatly among different centers because many are based on personal experience, where caregivers were trained, and non‐data‐driven beliefs. This has led to inconsist‐ ency in patient listing and donor acceptance rate, which seem to have affected outcomes and cost of delivery across different centers.2,3 For the first time, Godown and colleagues (in this issue) have studied this variability in attitudes among different pediatric heart transplant providers worldwide utilizing a survey administered through ISHLT.4 It is an important first step in understanding the practice variation and potential reasons associated with it. They demonstrated that practitioners not only disagree on methods of donor evaluation, but even if they agreed on the method, they disagreed on what criteria to use for that method. For example, only 45% used echo measure‐ ments to determine donor size, and almost all agreed that they used weight. However, acceptable minimum donor weight ranged from 50%‐150%. Although almost all centers use weight to determine fit, there is evidence demonstrating that weight is not a good predic‐ tor of cardiac size, especially when you are sizing for patients with dilated hearts and/or with multiple cardiac procedures for complex congenital heart defects. Some centers are utilizing 2D or 3D im‐ aging measurements successfully to assist with these decisions.5 Among other things, this study also highlights an important concern that programs’ decisions to accept certain offers are influenced by their apprehension for programmatic restrictions from regulatory bodies. Programs are currently evaluated by federal and state bod‐ ies on 1‐year post‐transplant outcomes; however, waitlist outcomes are not considered. This promotes risk‐averse behaviors and poten‐ tially leads to refusal of an otherwise usable donor.6 Program evalua‐ tion metrics should be balanced between listing and post‐transplant outcomes. Risk stratification of donor and recipient should also be considered in program evaluations to credit centers that are per‐ forming “high‐risk” donor or recipient transplants. More importantly, transplant centers should be provided with data on the outcomes of organs that they have declined that have been implanted elsewhere. This can then inform future practices. All in all, despite its limitation, this study underlines the growing evidence that the current system for donor allocation is flawed. The vast majority of pediatric heart transplant centers worldwide perform less than 10 transplants per year. Individually, we have a very limited number of patients from which to learn. However, we as a community have the numbers to progress toward data‐driven stan‐ dardization of donor selection practices. A consensus statement is being considered for this purpose and will enable us as a community to learn and move forward together. Another novel concept being studied now is matching recipient and donor risk so that the best matches are made to maximize post‐transplant outcomes, unlike the present system which appears to be focused on getting the sickest patients transplanted. Simply surviving to transplantation should not be the goal, rather the overall post‐transplant survival should be the focus of the community. High‐risk donors should be evaluated with the recipient's risk in mind, which dictates outcome much more than the donor in higher risk recipients (ie, on ECMO). This could potentially free up low‐risk donors for lower risk recipients while increasing the proportion of the donor pool that we can utilize. We should, with the data available, be able to create a system in which local practices and emotions are not driving forces to listing and ac‐ cepting organs, but a data‐driven algorithm that optimizes transplant matches and benefits the entire heart transplant population.

Time to stop spinning our individual wheels and start moving forward together.

Predicting postoperative pulmonary complications: The answer may be right in front of our noses!

Commentary: Is there life after cardiac death? Considering the challenges of heart donation after circulatory death.

Background: Infants experience the worst one-year post-heart transplant (HTx) survival of any other pediatric group. Although mechanical ventilatory (MV) requirement at the time of transplant is an established predictor of post-transplant mortality, the impacts of commonly co-utilized support modalities such as total parenteral nutrition (TPN)-dependence and paralytics are understudied. Methods: All infant HTx recipients from 2003 to 2020 in both the United Network for Organ Sharing and Pediatric Health Information System databases were identified (n = 1344) and categorized depending upon support requirement at the time of transplant—none (59%), MV-only (10%), MV + Paralytics (2%), TPN-dependence-only (15%), MV + TPN (10%), and MV + Paralytics + TPN (4%). The primary study aim was to characterize the impact of TPN-dependence and paralytics on one-year post-transplant survival (PTS). Results: Compared to no-support, supported infants were generally at higher risk and more ill at transplant, with greater rates of congenital heart disease, renal and hepatic dysfunctions, and inotrope requirements. Post-transplant hospital outcomes were inferior among supported patients; all support groups experienced longer post-transplant MV, intensive care unit, and hospital lengths of stay (all P < .05 vs no-support). Upon multivariable analysis, each support modality independently predicted 1-year mortality (MV vs no-MV: 1.54 [1.10-2.14]; MV + Paralytics vs neither: 2.02 [1.25-3.27]; TPN vs no-TPN: 1.53 [1.10-2.13]; P < .01 for all), whereas no-support was protective (HR 0.66 [95% CI 0.48-0.91]). Conclusions: Infants who require paralytics and/or who are TPN-dependent at the time of HTx experience worse one-year PTS. Such knowledge can assist in risk-stratification, and the identification of patients who would benefit from pretransplant optimization.

David L.S. Morales

Papers

Commentary: In a disappointing outcome, much can be learned

Time to stop spinning our individual wheels and start moving forward together.

Predicting postoperative pulmonary complications: The answer may be right in front of our noses!

Commentary: Is there life after cardiac death? Considering the challenges of heart donation after circulatory death.

Infants Who Require Total Parenteral Nutrition and Paralytics at Time of Heart Transplant Experience Inferior Post-Transplant Mortality