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Feeling the Beat in San Diego

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Jorge Silva Enciso, MD
University of California San Diego
San Diego, CA, USA

This year's meeting was enticed by the weather, catching up with friends & colleagues and mastering the skills of transplant and VAD management. It was a remarkable meeting with newer developments in all the fields- donor allocation, pediatric transplantation, AMR and VAD technology. On the front of new device technology, device-blood interaction was the focus of a late breaking clinical trial sessions. The heartmate 3 (HM3) showed superiority over the HMII for freedom of hemocompatibility related events-bleeding, neurological events and pump thrombosis (69 % HM3 vs. 55% HMII). Improved survival at 6 months for freedom from disabling stroke or pump replacement was seen in the HM3 cohort compared to HMII. Among factors observed, younger age and adequate anticoagulation were independently associated with reduction in events. A hemocompatibility score stratified by tiers of severity of events was developed. Interestingly though, the reduction in events for the HM3 cohort was related to lower pump thrombosis and need for exchange. This reflects ongoing efforts for devices to improve rheological properties of blood flow paths to avoid thrombosis, while the Achilles's heal remains on bleeding events. More research is needed to understand the interaction of bleeding and mechanical support through mechanistic studies, including impact of pulse on GI bleeding. On this note, one of the best symposia focused on the role of pulsatility in VAD patients. The session covered the benefits of pulsatility on endothelial function and regulation of flow through the microcirculation of end organs, the impact of continuous flow on vascular remodeling and function, the changes in central baroreceptor and sympathetic activity response to continuous vs. pulsatile flow with the former having increase sympathetic activity and ending on the value of pulsation relative to life's existence. A unique symposium which made us more excited to venture onto new horizons in device technology that attempt to imitate our natural function. In this regard, symposia focused on exercise in the VAD patients revealed the effects of pulsatility and pump speed modulation to achieve improvements in exercise duration. However, despite changes in speed and allowing for more aortic valve opening, there are still marginal effects on achieving peak VO2 and exercise duration comparable to heart transplant recipients or controls. As many speakers conclude, one of the limitations seen with CF-VAD support is the peripheral muscle blood flow and oxygen extraction. Despite this, with exercise training many VAD patients continue to achieve good quality of life, greater distances on 6-minute walk test and improvement in NYHA class.

Every year after the ISHLT meeting, we reflect on the science behind new discoveries and the uphill challenges that need to be surpassed to advance the fields of heart failure, transplant, VAD and pulmonary hypertension to the next level. As Descartes once said, "Car ce n'est pas assez d'avoir l'esprit bon, mais le principal est de l'appliquer bien" (It is not enough to have a good mind, the main thing is to use it well). We are eager for next year's meeting in Nice, not only because it is in Europe, but for the promising research and symposia that will be presented in such a fine city! ■

Disclosure Statement: The author has no conflicts of interest to disclose.

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