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A case series of cardiac amyloidosis patients supported by continuous-flow left ventricular assist deviceThe two main types of cardiac amyloidosis (CA), light chain (AL) and transthyretin (ATTR), typically cause restrictive cardiomyopathy (RCM) that may progress to advanced heart failure prompting consideration for orthotopic heart transplantation (OHT) or left ventricular assist device (LVAD). 1 Limited data exist on continuous-flow LVAD (CF-LVAD) use in CA patients, as this is not traditionally considered feasible due to the non-dilated and restrictive nature of the cardiac chambers. 2 Herein, we describe the outcomes of CA patients on CF-LVAD therapy at our institution.Our single-centre case series retrospectively identified seven CA patients (mean age 68 ± 9 years, 86% male, 71% African-American, 57% Intermacs 1-2) all supported by CF-LVAD (five centrifugal and two axial) from 2009 to 2021 (Table 1 and Supporting Information, Tables S1-S3). Five patients had ATTR amyloidosis (three hereditary due to p.Val142Ile and two wild type), and two had AL amyloidosis. This study complies with the Declaration of Helsinki and was approved by the institutional ethics committee with waiver for informed consent. Two CA patients with pulsatile pumps were excluded.The CF-LVAD served as bridge to transplant (BTT) in three patients and as destination therapy (DT) in four patients. The entire cohort was alive at 12 months post-LVAD and had a median survival of 2.01 years on LVAD support only and 3.6 years overall. The two AL amyloidosis patients with DT-LVAD survived the longest; one died after 48.3 months, and one remains alive at 66.9 months. Both achieved complete hematologic remission after anti-plasma cell therapy. Three patients (43%) died: one post-OHT from acute severe cellular rejection for non-compliance with immunosuppression; and two others whilst on device support, one from a fatal cerebral bleed after 43.1 months and the other from complications secondary to a device-related infection after 48.3 months.All patients had an LV ejection fraction (LVEF) ≤ 45%, with variable LV end-diastolic diameter (LVEDD). Two patients with a dilated LVEDD ≥ 5.8 cm were bridged to OHT. Of five patients with LVEDD ≤ 5.6 cm, four had intra-operative LV

Introduction: Continuous outpatient intravenous inotrope therapy (COIIT) is a treatment strategy used in stage D heart failure as a bridge to advanced therapies [bridge-todecision (BTD); bridge-to-mechanical support (BTMS); bridge-to-transplant (BTT)] or as palliation (PAL). Long-term survival associated with COIIT in the modern era of guideline directed medical and device therapy (GDMDT) is poorly defined. Our objective is to describe the survival of patients undergoing COIIT with milrinone or dobutamine in the modern era. Hypothesis: In patients undergoing COIIT for various indications, milrinone -which allows for more effective neurohormonal antagonism with beta blockadehas a more favorable survival profile than dobutamine. Methods: We retrospectively analyzed data from a large US registry of patients receiving COIIT (milrinone or dobutamine) from 2015-17. Patients with incomplete data or <7 days of follow-up were excluded. Survival estimates were obtained from Kaplan-Meier curves and censored at the time of transplant or mechanical circulatory support. Cox proportional hazards modeling was used to assess the independent association of inotrope type with overall survival. Results: Of 1,149 patients on COIIT (mean age 60 years, 29.9% female), 260 (22.6%) patients died during the study period. Mortality was higher in patients undergoing COIIT for palliation than for bridge therapy (1-year survival: 55.0% vs 65.6%, p<0.0001; median survival: 461 days vs 584 days). In the overall population, estimated 1-year survival rates were 71% among those treated with milrinone and 46% among those treated with dobutamine (p<0.0001). Patients treated with milrinone had a greater survival than patients treated with dobutamine in the BTT (p<0.0001), BTMS (p=0.001), and PAL (p<0.0001) cohorts at 1 year (Figure Panels A-C). After adjusting for age, indication, gender, and weight, milrinone use remained significantly associated with lower mortality compared to dobutamine use (HR 0.50, 95% CI 0.39-0.64, p<0.0001). Conclusions: In the largest data set reported to date of patients receiving COITT in the current era of GDMDT, milrinone use was associated with improved survival compared to dobutamine. A randomized, controlled trial in this growing patient population is warranted.