"Ball valve thrombus" which is a spherical free floating clot in left atrium is an often quoted, but uncommonly encountered complication in patients with severe mitral stenosis of rheumatic origin, who are in atrial fibrillation. We describe the case of a 31-year-old lady with rheumatic heart disease, severe mitral stenosis and moderately severe aortic stenosis who had undergone closed mitral valvotomy 13 years ago. The patient presented with an episode of non-exertional syncope and breathlessness on exertion of 6 months duration and was in normal sinus rhythm. Echocardiography facilitated ante-mortem diagnosis and prompt institution of surgery was life saving.

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Purpose: The 2018 UNOS heart allocation policy change was intended to prioritize sicker patients while also improving waitlist outcomes. We sought to compare competing outcomes for patients bridged to heart transplantation using Impella devices one year prior to and after the UNOS Allocation Policy change in October 2018. Methods: The UNOS database was queried for all adult patients in whom an Impella device (CP/5.0) was used as a bridge to heart transplantation in the 12 month period before and after the UNOS policy change. 28 patients in the pre-policy change and 56 patients in the post-policy change were supported with Impella and underwent heart transplantation. Patients who were younger than 18 years old, lost to follow-up, or who had multi-organ transplant were excluded. Baseline characteristics were compared using Mann-Whitney U test and Chisquare test as appropriate. Competing outcomes analysis was performed to compare (1) death or deterioration, (2) heart transplant or recovery, or (3) continuation on waitlist at 6 months. Results: There were no differences between the pre-and post-allocation change groups in regards to recipient age, donor age, gender, ethnicity, ischemic time, and serum creatinine at time of transplant, and hemodynamics. Patients in the post-policy change group had greater rates of transplantation (76.7% vs 39.3%, p<0.001) and decreased proportion of patients who remained on the waitlist (12.5% vs 42.9%, p=0.002). There was no difference in wait list mortality (10.7% vs 17.9%, p=0.34). Conclusion: Impella devices were used more frequently in the one year after the allocation policy change. Early after the UNOS allocation policy change, patients bridged with Impella were more likely to be transplanted however with no difference in waitlist mortality. Additional analysis is needed to better understand whether these results will persist over time as more patients are transplanted with Impella support.

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