Contemporary Left Ventricular Assist Device Outcomes in an Aging Population: An STS INTERMACS Analysis.

BACKGROUND: Survival, functional outcomes, and quality of life after left ventricular assist device (LVAD) are ill-defined in elderly patients, and with new-generation devices. OBJECTIVES: This study sought to evaluate survival, functional outcomes, and quality of life after LVAD in contemporary practice. METHODS: Adults receiving durable LVADs between January 1, 2010, and March 1, 2020, were identified from the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) database. The primary outcome was adjusted survival; secondary outcomes included quality of life rated using a visual analogue scale (where 0 represents "worst health" and 100 "best health"); 6-minute walk distance; stroke; device malfunction; and rehospitalization, stratified by patient age. Median follow-up was 15 months (IQR: 6-32 months). RESULTS: The cohort comprised 68.9% (n = 16,808) patients aged <65 years, 26.3% (n = 6,418) patients aged 65-75 years, and 4.8% (n = 1,182) patients aged >75 years, who were predominantly male (n = 19,119, 78%) and on destination therapy (n = 12,425, 51%). Competing outcomes analysis demonstrated mortality (70% CIs) of 34% (33%-34%), 54% (54%-55%), and 66% (64%-68%) for patients aged <65, 65-75, and >75 years, respectively, which improved during the study in patients aged >75 years. Newer-generation devices were associated with reduced late mortality (HR: 0.35; 95% CI: 0.25-0.49). Stroke, device malfunction or thrombosis, and rehospitalizations decreased with increasing age (all P < 0.01). Median 6-minute walk distance increased from 0 feet (IQR: 0-665 feet) to 1,065 feet (IQR: 642-1,313 feet) (P < 0.001), and quality of life improved from 40 (IQR: 15-60) to 75 (IQR: 60-90) (P < 0.001) after LVAD in all age groups. CONCLUSIONS: In elderly patients, LVADs are associated with increased functional capacity, similar improvements in quality of life, and fewer complications compared with younger patients.

Psychosocial Risk and Its Association With Outcomes in Continuous-Flow Left Ventricular Assist Device Patients.

BACKGROUND: Advanced heart failure therapies such as left ventricular assist device (LVAD) implantation require intricate follow-up and complex care. We sought to explore the burden of psychosocial risk factors among patients with LVAD and their impact on postimplant outcomes using the Interagency Registry for Mechanically Assisted Circulatory Support. METHODS: Adult patients in the Interagency Registry for Mechanically Assisted Circulatory Support requiring durable LVAD between 2008 and 2017 were included. Individuals were determined to have psychosocial risk if they had one of the following: (1) limited social support; (2) limited cognition; (3) substance abuse (alcohol and drug); (4) severe psychiatric disease (including major depression and other major psychiatric diagnosis); and (5) repeated noncompliance. Univariate and multivariate Cox proportional hazard regression models were used to analyze predictors of survival and complications. RESULTS: A total of 15 403 continuous-flow LVAD recipients were included. A total of 3163 (20.5%) had one or more psychosocial risk factors. The most prevalent psychosocial risk factor was substance abuse in 1941 (12.6%) recipients. Patients with psychosocial risk factors were significantly younger at LVAD implant, less likely to be White, and less likely to be female compared with those without psychosocial risk, P<0.001 for all. Patients with psychosocial risk were significantly more likely to receive an LVAD as destination therapy, P<0.001. In adjusted models, patients with psychosocial risk were at increased hazards for device-related infection, gastrointestinal bleeding, pump thrombosis, and readmission and reduced hazards for cardiac transplantation (P<0.05 for all). There was no statistically significant difference in survival on pump support or stroke. CONCLUSIONS: Psychosocial risk is an important component of patient selection for advanced heart failure therapies. Addressing these specific components may help improve access to advanced therapies and post-LVAD outcomes.

Effect of combined aerobic and resistance training on peak oxygen consumption, muscle strength and health-related quality of life in patients with heart failure with reduced left ventricular ejection fraction: a systematic review and meta-analysis.

OBJECTIVE: The aim of this study was to investigate the effects of combined aerobic and resistance training on peak oxygen consumption (peak VO2), minute ventilation/carbon dioxide production (VE/VCO2 slope), muscle strength and health-related quality of life (HRQoL) in heart failure patients with reduced left ventricular ejection fraction (HFrEF). METHODS: We searched Cochrane, Pubmed, and PEDro (from the earliest date available to September 2018) for RCTs that evaluated the effects of combined aerobic and resistance training in HFrEF patients. Weighted mean differences (WMD), standardized mean difference (SMD), and 95% confidence interval (CI) were calculated. RESULTS: 39 studies met the study criteria, including 2008 patients, 14 compared combined aerobic and resistance training versus aerobic training, and 25 compared combined aerobic and resistance training versus control. Compared to aerobic training, combined aerobic and resistance training resulted in improvement in muscle strength SMD 0.7 (95% CI: 0.3 to 1.0 N = 167) and, HRQoL WMD -2.6 (95% CI: -5.0 to -0.1 N = 138). A nonsignificant difference in peak VO2 and VE/VCO2 slope was found for participants in the combined aerobic and resistance training group compared with aerobic training group. Compared to control, combined aerobic and resistance training resulted in improvement in peak VO2 WMD 2.9 (95% CI: 1.6 to 4.4 N = 638), muscle strength SMD 0.64 (95% CI: 0.4 to 0.9 N = 315) and, HRQoL WMD -9.8 (95% CI: -15.2 to -4.5 N = 524). CONCLUSIONS: Combined aerobic and resistance training improves peak VO2, muscle strength and HRQoL and should be considered as a component of care of HFrEF patients.

Development of a yoga module targeting cardiovascular health for patients with post-myocardial left ventricular dysfunction in India.

BACKGROUND: Yoga is known to contribute towards cardiovascular health. This paper describes the development of a need-based yoga program which is suitable to be integrated into the cardiac rehabilitation of post-myocardial infarction patients with left ventricular dysfunction. MATERIALS AND METHODS: Based on the assessment of the need of the patients, literature review, and expert opinion, a yoga module was developed using the qualitative method of inquiry. The program included warm-up exercises, yogic asanas, pranayama, meditation and counseling sessions. A structured questionnaire eliciting comments on the contents was given independently to ten experts working in the field of health and yoga for validation. The final module was derived after incorporating the suggestions of the experts. RESULTS: Using the raters' expertise in cardiology and yoga practice, the practices which constitute the module were optimized. Majority of the experts (raters) agreed with the duration of 1 h training for 1month under supervision as adequate for subsequent practice at home. There was a 0.786 inter-rater reliability estimated using the interclass coefficient (ICC) and 0.789 internal consistency of the questions, measured using Cronbach's alpha. Both values indicate "good" reliability and consistency of the yoga module. CONCLUSION: The developed yoga module was found to be acceptable. Future randomized control trials will be necessary to validate the effectiveness of this module and if the module demonstrates to be effective by clinical studies, it may add a therapeutic option in the rehabilitation of patients with heart failure following myocardial infarction, which can be applied in the hospitals and community level.

Associations Between Left Ventricular Dysfunction and Brain Structure and Function: Findings From the SABRE (Southall and Brent Revisited) Study.

BACKGROUND: Subclinical left ventricular (LV) dysfunction has been inconsistently associated with early cognitive impairment, and mechanistic pathways have been poorly considered. We investigated the cross-sectional relationship between LV dysfunction and structural/functional measures of the brain and explored the role of potential mechanisms. METHOD AND RESULTS: A total of 1338 individuals (69±6 years) from the Southall and Brent Revisited study underwent echocardiography for systolic (tissue Doppler imaging peak systolic wave) and diastolic (left atrial diameter) assessment. Cognitive function was assessed and total and hippocampal brain volumes were measured by magnetic resonance imaging. Global LV function was assessed by circulating N-terminal pro-brain natriuretic peptide. The role of potential mechanistic pathways of arterial stiffness, atherosclerosis, microvascular disease, and inflammation were explored. After adjusting for age, sex, and ethnicity, lower systolic function was associated with lower total brain (beta±standard error, 14.9±3.2 cm3; P<0.0001) and hippocampal volumes (0.05±0.02 cm3, P=0.01). Reduced diastolic function was associated with poorer working memory (-0.21±0.07, P=0.004) and fluency scores (-0.18±0.08, P=0.02). Reduced global LV function was associated with smaller hippocampal volume (-0.10±0.03 cm3, P=0.004) and adverse visual memory (-0.076±0.03, P=0.02) and processing speed (0.063±0.02, P=0.006) scores. Separate adjustment for concomitant cardiovascular risk factors attenuated associations with hippocampal volume and fluency only. Further adjustment for the alternative pathways of microvascular disease or arterial stiffness attenuated the relationship between global LV function and visual memory. CONCLUSIONS: In a community-based sample of older people, measures of LV function were associated with structural/functional measures of the brain. These associations were not wholly explained by concomitant risk factors or potential mechanistic pathways.

Electrophysiological correlates of word recognition memory process in patients with ischemic left ventricular dysfunction.

OBJECTIVE: The relationship between left ventricular ejection fraction (LVEF) and cognitive performance in patients with coronary artery disease without overt heart failure is still under debate. In this study we combine behavioral measures and event-related potentials (ERPs) to verify whether electrophysiological correlates of recognition memory (old/new effect) are modulated differently as a function of LVEF. METHODS: Twenty-three male patients (12 without [LVEF>55%] and 11 with [LVEF<40%] left ventricular dysfunction), and a Mini Mental State Examination score >25 were enrolled. ERPs were recorded while participants performed an old/new visual word recognition task. RESULTS: A late positive ERP component between 350 and 550ms was differentially modulated in the two groups: a clear old/new effect (enhanced mean amplitude for old respect to new items) was observed in patients without LVEF dysfunction; whereas patients with overt LVEF dysfunction did not show such effect. In contrast, no significant differences emerged for behavioral performance and neuropsychological evaluations. CONCLUSIONS: These data suggest that ERPs may reveal functional brain abnormalities that are not observed at behavioral level. SIGNIFICANCE: Detecting sub-clinical measures of cognitive decline may contribute to set appropriate treatments and to monitor asymptomatic or mildly symptomatic patients with LVEF dysfunction.

Variable Contribution of Heart Failure to Quality of Life in Ambulatory Heart Failure With Reduced, Better, or Preserved Ejection Fraction.

OBJECTIVES: The relative contribution of heart failure (HF) compared with other medical and nonmedical factors on diminished quality of life (QOL) across subtypes with reduced, better, and preserved left ventricular ejection fraction (LVEF) in a large ambulatory HF population was evaluated. BACKGROUND: Dominant factors influencing limited QOL in patients with HF have not been investigated. METHODS: Before routine HF clinic visits, 726 patients with ambulatory HF (mean age 56 ± 15 years, 37% women) completed a 1-page questionnaire that assessed QOL and relative contributions of HF compared with other medical and nonmedical factors to their QOL limitations. Visual analogue scales were used to assess overall QOL, breathing, and energy level. Results were compared across reduced (57%), preserved (16%) and better (improvement in LVEF ≥50%) (19%) subtypes. RESULTS: Just under one-half of patients (48%) rated QOL as limited dominantly by HF, 19% rated HF and medical problems as equally limiting, 18% cited medical problems as dominant, and 15% cited nonmedical factors. Patients with HF with better LVEF had the highest overall QOL score and less dyspnea burden than those with HF with preserved EF. Independent correlates of HF-dominated diminished QOL were prior cardiac surgery, worse New York Heart Association functional class, renin-angiotensin-aldosterone antagonism, use of diuretic agents, lower body mass index, lower LVEF, and lack of arthritis or history of cancer. CONCLUSIONS: Fewer than one-half of patients with ambulatory HF rated HF as the greatest limitation to their QOL, suggesting that this important outcome will be difficult to affect by HF-targeted therapies alone, particularly in those with higher LVEFs and comorbidities. Patients with HF with better LVEF represent a distinct subtype with better overall QOL.

Efficacy and safety of catheter ablation vs. rate control of atrial fibrillation in systolic left ventricular dysfunction : A meta-analysis and systematic review.

PURPOSE: It is unclear what constitutes the optimal strategy for management of atrial fibrillation (AF) in patients with systolic left ventricular (LV) dysfunction. We hypothesized that catheter ablation of AF had benefits compared with rate control in patients with systolic LV dysfunction. METHODS: PubMed, Embase, and the Cochrane Library were searched for randomized controlled trials and nonrandomized, observational studies. Weighted mean differences (WMD) and 95 % confidence intervals (CIs) were calculated to compare the improvement of left ventricular ejection fraction (LVEF), functional capacity, and quality of life between a catheter ablation group and a rate control group. RESULTS: Six trials with 324 patients were included in the analysis. Patients in the catheter ablation group had greater improvement of LVEF (WMD: 8.89; 95 % CI: 6.93-10.86; p < 0.001), 6-min walk distance (WMD: 46.9; 95 % CI: 28.5-65.4; p < 0.001), and lower Minnesota Living With Heart Failure Questionnaire (MLHFQ) scores (WMD: - 19.6; 95 % CI: - 23.6-- 15.7; p < 0.001) compared with patients in the rate control group. Overall, there were only ten procedure-related events and the procedure-related events rate was 4.9 % per procedure and 5.6 % per patient. CONCLUSION: The present analysis suggests that catheter ablation of AF has benefits in terms of an improvement in LVEF, in functional capacity, and in quality of life compared with rate control in patients with systolic LV dysfunction, and the risk of complications related to procedures is acceptable.

Association between left ventricular global longitudinal strain, health-related quality of life and functional capacity in chronic kidney disease patients with preserved ejection fraction.

AIM: Patients with chronic kidney disease (CKD) have a significant burden of dyspnoea and fatigue in spite having normal left ventricular (LV) ejection fraction (EF). Global longitudinal strain (GLS) can detect subtle changes in LV function. This study aimed to evaluate the relationship between LV function, functional capacity and quality of life (QOL) in CKD patients with preserved EF. METHODS: A cross-sectional study of patients with stage 3/4 CKD (n = 108). Clinical characteristics, biochemical data, functional capacity (6-min walk test (6MWT), timed up and go (TUG) test) and QOL (short form-12 (SF-12v2™) ) were measured. Echocardiogram was used to assess GLS, EF and diastolic function (E/A, e' and E/e'). RESULTS: The mean age was 58.1 ± 9.9 years, 55.6% were men, estimated glomerular filtration rate was 44.8 ± 10.6 mL/min/1.73 m(2), GLS was -18.5 ± 3.6% and 19.4% had impaired GLS (>-16%). Patients with impaired GLS had a significantly shorter 6MWT and slower TUG test compared with patients with preserved GLS. Bivariate analysis showed GLS and E/e' correlated with distance walked in 6MWT (GLS (r = -0.24, P = 0.02); E/e'(r = -0.38, P = 0.002) ). Following adjustment for potential confounders, GLS remained independently associated with 6MWT (model R(2) = 0.37, P < 0.001). Mean physical component summary scores (PCS) and mental component summary scores (MCS) were 43.0 ± 10.2 and 50.9 ± 9.5. There was no cardiac parameter that was independently associated with PCS. However women, lower systolic blood pressure and GLS was associated with lower MCS (model R(2) = 0.30, P < 0.001). CONCLUSION: GLS was associated with measures of functional capacity and QOL in CKD patients with preserved EF.

Investigating the role of acute mental stress on endothelial dysfunction: a systematic review and meta-analysis.

Chronic stress is a known risk factor for both endothelial dysfunction and cardiovascular disease (CVD), but less is known of how acute mental stress affects the vasculature. In this systematic review and meta-analysis, we analyzed the impact of acute mental stress on flow-mediated dilation (FMD), an indicator of endothelial function. We searched the Medline, Cochrane, EMBASE, and ISI Web of Knowledge databases through May 2014, to identify publications in English-language journals. The primary outcome was the change in FMD from baseline to the time of measurement. We also assessed the risk of bias and the heterogeneity of included studies. Our search identified eight prospective studies, which displayed significant heterogeneity. Four studies measured FMD while the subject was performing the task; six measured FMD after the task had been completed. The total number of participants was 164. The pooled results indicate that FMD did not change significantly while the task was being performed (pooled difference in means: -0.853; 95 % confidence interval (CI), -3.926/2.220; P = 0.586); however, FMD measured after the task was completed was significantly less than baseline (pooled difference in means: -2.450; 95 %CI, -3.925/-0.975; P = 0.001). In conclusions, our findings provide evidence that an acute stressful experience has a delayed, negative impact on the function of the endothelium. Repeated exposure to short-term stress may lead to permanent injury of the vasculature. Therefore, assessment of patients' exposure to both repeated acute mental stress and chronic stress may be useful in determining their risk of developing CVD.

Decision making for destination therapy left ventricular assist devices: "there was no choice" versus "I thought about it an awful lot".

BACKGROUND: Destination therapy left ventricular assist devices (DT LVADs) are one of the most invasive medical interventions for end-stage illness. How patients decide whether or not to proceed with device implantation is unknown. We aimed to understand the decision-making processes of patients who either accept or decline DT LVADs. METHODS AND RESULTS: Between October 2012 and September 2013, we conducted semistructured, in-depth interviews to understand patients' decision-making experiences. Data were analyzed using a mixed inductive and deductive approach. Twenty-two eligible patients were interviewed, 15 with DT LVADs and 7 who declined. We found a strong dichotomy between decision processes with some patients (11 accepters) being automatic and others (3 accepters, 7 decliners) being reflective in their approach to decision making. The automatic group was characterized by a fear of dying and an over-riding desire to live as long as possible: "[LVAD] was the only option I had…that or push up daisies…so I automatically took this." By contrast, the reflective group went through a reasoned process of weighing risks, benefits, and burdens: "There are worse things than death." Irrespective of approach, most patients experienced the DT LVAD decision as a highly emotional process and many sought support from their families or spiritually. CONCLUSIONS: Some patients offered a DT LVAD face the decision by reflecting on a process and reasoning through risks and benefits. For others, the desire to live supersedes such reflective processing. Acknowledging this difference is important when considering how to support patients who are faced with this complex decision.

Choices for patients "without a choice": Interviews with patients who received a left ventricular assist device as destination therapy.

BACKGROUND: Patients undergo major physical and psychological changes after implantation of a left ventricular assist device as destination therapy (DT). We sought to qualitatively study outcomes and attitudes of patients after DT. METHODS AND RESULTS: Ambulatory outpatients with DT at our institution were invited to be interviewed between June and August 2011. In-person interviews were audio-recorded, transcribed, and analyzed qualitatively using thematic analysis. The study included 12 patients (11 men) from the Midwestern United States with a median age of 71.5 years (range, 33-78 years). Interviews were conducted at a median (range) time of 1.37 (0.43-5.04) years after DT implantation. Most patients were white (n=11), married (n=10), and Christian (n=10). We identified 6 themes commonly discussed by the interviewees: preparedness planning, new lease on life, optimizing support networks, systemic limitations, reflections on time, and communication matters. Analysis revealed that most patients saw DT as their only choice, despite other alternatives. CONCLUSIONS: Ambulatory patients reported varied experiences after DT but commonly reported gratitude for improved functional status and a perception of improved symptom burden. Recommendations for improving post-DT care include developing patient support systems, systematizing education for community providers, and expanding respite services.

Neurogenic stress cardiomyopathy in heart donors.

Cardiac transplantation is severely restricted by donor availability. Left ventricular dysfunction due to neurogenic stress cardiomyopathy is often seen during donor evaluation and often presents a clinical dilemma for procurement. We report a case of a 23-year-old man with severe left ventricular dysfunction whose heart was successfully procured for transplantation. The brief case report is followed by an extensive review of neurogenic stress cardiomyopathy as well as donor evaluation for cardiac transplantation in the setting of such cardiomyopathy.

Clinical and socio-demographic predictors of postoperative vital exhaustion in patients after cardiac surgery.

BACKGROUND: Vital exhaustion, a psychological state characterized by extreme fatigue, is an independent predictor of future cardiac events. However, the attributes of vital exhaustion following coronary artery bypass (CABG) surgery are poorly understood. OBJECTIVE: The study objective was to assess correlates of vital exhaustion following CABG surgery. METHODS: In a descriptive, exploratory study, 42 patients who had CABG surgery were evaluated for exhaustion 4-8 weeks post-hospital discharge. Demographic and clinical data were obtained from self-report and medical chart review. RESULTS: Of the total sample (mean age 67.9 ± 12.5, 90% male, 70% Caucasian, 3.12 ± 1.3 grafts), approximately 41% reported exhaustion. When compared to their exhausted post-CABG counterpart, non-exhausted post-CABG patients had a significantly higher frequency of preoperative insulin use. Exhausted patients were significantly more likely to have higher left ventricular ejection fraction ([LVEF], OR: 1.07, p = 0.04), and elevated hemoglobin (OR: 2.98, p = 0.03) and eosinophils (OR: 1.02, p = 0.02) than those who were not exhausted. CONCLUSION: Clinicians should evaluate all patients for exhaustion post-CABG surgery; patients with elevated LVEF, hemoglobin, and eosinophil levels warrant increased scrutiny.

Neuropsychological patterns differ by type of left ventricle dysfunction in heart failure.

Cognitive impairment is common among individuals with heart failure. The purpose of this study was to compare cognitive profiles of individuals with systolic and diastolic dysfunction. Eighty individuals with heart failure completed the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Mini-Mental State Examination, Trail Making Test, and letter fluency. Approximately 25% of individuals with systolic dysfunction were impaired on the RBANS Total Scale score, compared with only 3% in the diastolic group. Additionally, individuals with systolic dysfunction scored lower than those with diastolic dysfunction on tests of immediate and delayed memory. The groups did not differ on tests of visuospatial skills, but there were mixed results on the RBANS Attention and Language subtests. Overall, the results of this study suggest that individuals with different types of cardiac dysfunction (systolic and diastolic dysfunction) demonstrate differential patterns of performance on neuropsychological tests. These findings have important clinical implications.