Promoting Type 1 Diabetes Self-care Management in the Hospital: Can It Be Done?

PURPOSE: The specific aim of the study was to determine whether there was an increased time in target glucose range for individuals with type 1 diabetes mellitus who were permitted to self-manage their insulin plan while hospitalized. DESIGN: A retrospective chart review was conducted of 60 inpatients with type 1 diabetes mellitus who met the criteria to self-manage their diabetes care with the use of their continuous subcutaneous insulin infusion pump or a multiple daily injection insulin regimen. A comparison of the 2 groups was examined to assess differences in glucose outcomes and glycemic stability. RESULTS: Seven hundred fifty-three glucose results were examined. The total number of hypoglycemic events in both groups was 37. The number of glucose values labeled as stable was 405, and the remaining 311 glucose values were categorized as hyperglycemic. There were no statistically significant differences in glucose levels between the 2 groups. CONCLUSION: No patients experienced severe hypoglycemia leading to cognitive impairment or severe hyperglycemia leading to diabetic ketoacidosis. The outcomes of this study suggest that diabetes self-management practices in select individuals hospitalized with type 1 diabetes mellitus can contribute to greater glucose stability and time in targeted glucose range.

Association of SGLT-2 Inhibitors With Treatment Satisfaction and Diabetes-Specific and General Health Status in Adults With Cardiovascular Disease and Type 2 Diabetes.

Background It is unknown if initiation of a sodium-glucose cotransporter-2 inhibitor (SGLT-2i) is associated with changes in patient-reported health status outside of clinical trials. Methods and Results Using a prospective observational study design, adults with type 2 diabetes and cardiovascular disease were recruited from 14 US hospitals between November 2019 and December 2021 if they were new users of noninsulin antidiabetic medications. The primary outcome was change in 6-month diabetes treatment satisfaction. Secondary outcomes included diabetes-related symptom distress, diabetes-specific quality of life, and general health status for all patients and based on cardiovascular disease type. Inverse probability of treatment weight using propensity score was performed to compare outcome changes based on medication use. Of 887 patients (SGLT-2i: n=242) included in the inverse probability of treatment weight analyses, there was no difference in changes in treatment satisfaction in SGLT-2i users compared with other diabetes medication users (0.99 [95% CI, -0.14 to 2.13] versus 1.54 [1.08 to 2.00], P=0.38). Initiating an SGLT-2i versus other diabetes medications was associated with a greater reduction in ophthalmological symptoms (-3.09 [95% CI, -4.99 to -1.18] versus -0.38 [-1.54 to 0.77], P=0.018) but less improvement in hyperglycemia (1.08 [-2.63 to 4.79] versus -3.60 [-5.34 to -1.86], P=0.026). In subgroup analyses by cardiovascular disease type, SGLT-2i use was associated with a greater reduction in total diabetes symptom burden and neurological sensory symptoms in patients with heart failure. Conclusions Among patients with type 2 diabetes and cardiovascular disease, initiating an SGLT-2i was not associated with changes in diabetes treatment satisfaction, total diabetes symptoms, diabetes-specific quality of life, or general health status.

Nighttime sleep and daytime sleepiness patterns among left ventricular assist device patients.

Despite the high prevalence of sleep disturbance in the heart failure population, information about its consequence on daytime function in patients with left-ventricular assist devices (LVADs) is limited. This study examined the nighttime and daytime sleep patterns and changes from pre-implant to 6 months post-implant. This study included 32 LVAD patients. Demographics, nighttime and daytime sleep variables were collected pre-implant and at 1, 3, and 6 months post-implant. Wrist actigraphy and self-report questionnaires measured objective and subjective sleep, respectively. Objective nighttime sleep data were sleep efficiency (SE), sleep latency (SL), total sleep time (TST), wake after sleep onset (WASO), and sleep fragmentation (SF). Objective daytime sleep data were nap times. Self-reported Subjective Sleep Quality Scale (SSQS) and Stanford Sleepiness Scale (SSS) were subjective measures. Increased SF and WASO scores and decreased TST and SE scores were found pre-LVAD implant, indicative of poor sleep quality. TST, SE, naptime and SSQS scores were higher at 3 and 6 months post-implant compared to baseline. Decreases in TST and SF scores were observed at 3 and 6 months post-implant along with increases in SSS scores. Increasing SSS scores and decreasing overall scores from pre- and up to 6 months post-implant suggest improvement in daytime function. This study provides information on sleep-daytime function in the LVAD patient population. Improvements in daytime sleepiness do not imply "good" sleep quality, consistent with the extant knowledge in LVAD literature. Future investigations should elucidate the mechanism by which sleep-daytime function influences quality of life.

Figure of eight suture technique in aortic valve replacement decreases prosthesis-patient mismatch.

BACKGROUND: While the pledget suture technique has been the standard for surgical aortic. valve replacement (AVR), discussion continues regarding the possibility of the nonpledget suture technique to produce superior structural and hemodynamic parameters. This study aims to assess the effectiveness of the figure-of-eight suture technique in AVR, as determined by the incidence of prosthesis-patient mismatch (PPM). METHODS: We reviewed records of patients (N = 629) who underwent a surgical AVR procedure between January 2011 and July 2018 at a single institution. Indexed effective orifice area values and PPM incidence were calculated from implanted valve size and patient body surface area. Incidence of none, moderate, and severe PPM was compared across AVR suture techniques. RESULTS: A total of 570 pledget and 59 figure-of-eight patients were compared for incidence of PPM. Patients who received AVR with the pledget suture technique had significantly lower echocardiographic measurements of baseline ejection fraction than patients who had received AVR with the figure-of-eight suture technique (p = 0.003). Patients who received the figure-of eight suture had a 14% decrease in moderate PPM compared to patients who received the pledget suture (p = 0.022). Patients who received the figure-of-eight suture also had a significantly higher rate of no PPM (p = 0.044). CONCLUSIONS: The use of the figure-of-eight suture technique in AVR can reduce the incidence of moderate PPM. While the pledget suture is the standard technique in AVR, the figure-of-eight suture technique may offer better structural and hemodynamic outcomes, especially for patients with a smaller aortic annulus.

Quality of Anticoagulation With Phenprocoumon and Warfarin in Left Ventricular Assist Device Patients: A Multicenter Study.

VISUAL ABSTRACT: of key results. INR, international normalized ratio; TTR, time in therapeutic range; PTR, percentage of tests in range; HRAE, hemocompatibility-related adverse event; FFUV, first follow-up visit; GIB, gastrointestinal bleeding; HR, hazard ratio.http://links.lww.com/ASAIO/A961.

Anomalous Origin of the Left Coronary Artery From the Right Pulmonary Artery of an Infant.

A female presented 2 weeks after birth with an unbalanced atrioventricular canal, double outlet right ventricle, mild pulmonary stenosis, and patent ductus arteriosus that eventually caused pulmonary over circulation. After pulmonary artery banding, she experienced myocardial ischemia, suggesting interference with coronary blood flow by the band that had been placed on the main pulmonary trunk. The band was removed and revised to bilateral branch pulmonary artery banding, and cardiac function improved. An anomalous left coronary artery from the underside of the right pulmonary artery was identified. Eight weeks later, the patient underwent coronary transfer and reimplantation of the left coronary artery into the aorta followed by main pulmonary artery banding. She subsequently underwent bidirectional Glenn.

Anemia and outcomes following left ventricular assist device implantation.

BACKGROUND: Patients with concomitant anemia and congestive heart failure have poor outcomes. The prevalence and clinical risk of anemia in patients receiving durable left ventricular assist devices (LVAD) remain unknown. METHODS: We retrospectively analyzed patients who underwent LVAD implantation between 2014 and 2018. The association between hemoglobin level at the time of index discharge and the one-year composite endpoint of heart failure readmissions or hemocompatibility-related adverse events was investigated. RESULTS: A total of 168 patients (57 [48, 66] years old, 123 males) were included and stratified into a classification of anemia (hemoglobin <9.7 g/dl, N = 99) or non-anemia (N = 69). The anemia group had a higher one-year incidence of the composite endpoint (56% vs 36%, p = .013) with an adjusted hazard ratio of 1.83 (95% confidence interval 1.08-2.82). Patients with anemia also experienced suboptimal bi-ventricular unloading. CONCLUSIONS: Anemia was prevalent in LVAD patients and associated with a greater risk of heart failure and hemocompatibility-related adverse events. The optimal threshold for therapeutic intervention in response to post-LVAD anemia needs further investigation.

Hyperkalemia in Patients With Left Ventricular Assist Devices.

Background: Both hypo- and hyperkalemia are associated with adverse events in heart failure patients. Their effects on patients with left ventricular assist devices (LVADs) remains unknown. Methods and Results: The cohort included consecutive patients undergoing LVAD implantation between 2014 and 2018. In all, 170 patients (median age 56 years; 117 males) were stratified according to serum potassium levels 1 month after implantation into 3 groups: hypokalemia (<3.5 mEq/L; n=15), normokalemia (n=146), and hyperkalemia (>5.0 mEq/L; n=9). Compared with the normokalemia group, the adjusted hazard ratios for 1-year mortality were 0.91 (95% confidence interval [CI] 0.21-3.92) for hypokalemia and 4.14 (95% CI 1.47-11.65) for hyperkalemia. In the hyperkalemia group, the prevalence of renin-angiotensin-aldosterone system inhibitors decreased and serum potassium levels normalized following the first month. Conclusions: Hyperkalemia was associated with increased mortality during LVAD support. Management of serum potassium needs further investigation.

Pediatric aortic valve repair: Any development in the material for cusp extension valvuloplasty?

BACKGROUND: Aortic cusp extension is a technique for aortic valve (AV) repairs in pediatric patients. The choice of the material used in this procedure may influence the time before reoperation is required. We aimed to assess postoperative and long-term outcomes of patients receiving either pericardial or synthetic repairs. METHODS: We conducted a single-center, retrospective study of pediatric patients undergoing aortic cusp extension valvuloplasty (N = 38) with either autologous pericardium (n = 30) or CorMatrix (n = 8) between April 2009 and July 2016. Short- and long-term postoperative outcomes were compared between the two groups. Freedom from reoperation was compared using Kaplan-Meier analysis. Degree of aortic stenosis (AS) and aortic regurgitation (AR) were recorded at baseline, postoperatively, and at outpatient follow-up. RESULTS: At 5 years after repair, freedom from reoperation was significantly lower in the CorMatrix group (12.5%) compared to the pericardium group (62.5%) (p = .01). For the entire cohort, there was a statistically significant decrease in the peak trans-valvar gradient between preoperative and postoperative assessments with no significant change at outpatient follow-up. In the pericardium group, 28 (93%) had moderate to severe AR at baseline which improved to 11 (37%) postoperatively and increased to 21 (70%) at time of follow-up. In the biomaterial group, eight (100%) had moderate to severe AR which improved to three (38%) postoperatively and increased to seven (88%) at time of follow-up. CONCLUSION: In terms of durability, the traditional autologous pericardium may outperform the new CorMatrix for AV repairs using the cusp extension method.

A model for continued LVAD patient success: A 4-year readmission-free HeartMate 3 postoperative course.

Unplanned readmissions frequently occur following the implantation of a durable left ventricular assist device (LVAD) due to complications such as gastrointestinal bleeding and driveline infection. There is a paucity of literature describing the incidence of unplanned readmission in patients with a HeartMate 3 (HM3) Left Ventricular Assist System. In this report, we present the successful outcome of a patient with an HM3 LVAD who has experienced no unplanned readmissions in the 4-year post-implant phase. To our knowledge, this is the longest readmission-free case after HM3 implantation. A successful patient outcome was enabled by the use of the modular HM3 device, the postoperative prescription of beta-blockers and omega-3, the presence of strong social support, and open communication between the patient's caregivers and the LVAD team. Reducing the instance of unplanned readmission confers clinical benefits to the patient, as well as reducing the cost burden on the patient and the healthcare system.

Aortic root aneurysm repair in a neonate with Loeys-Dietz syndrome.

Loeys-Dietz syndrome is a connective tissue disorder known to cause aggressive aortopathy in paediatric patients, but it is extremely rare for cardiovascular events to present during infancy. We report the first successful aortic repair in a neonate with LDS presenting in extremis with an early onset, massive aortic aneurysm.

An international survey: Tobacco smoking cessation strategies within left ventricular assist device centers.

BACKGROUND: Tobacco smoking is a significant source of morbidity in patients with a durable left ventricular assist device. While various cessation strategies have been investigated, the ability of ventricular assist device centers to implement a successful tobacco cessation program remains uncertain. We explored various cessation strategies employed by ventricular assist device centers and assessed perspectives of their effectiveness, as well as institutional investment in these programs. METHODS: A 37-question online self-report survey was created using Survey Monkey® and distributed worldwide. We investigated (1) programmatic strategies utilized for smoking cessation, (2) the respondent's perspective on the effectiveness of these strategies, (3) the structure with which these therapies are administered, and (4) overall organizational support for these treatments. RESULTS: A total of 47 centers worldwide completed the survey. The most common methods of tobacco cessation were pharmacologic and nicotine replacement therapy (78% and 66%). However, only about half (47% and 50%, respectively) of the centers indicated that these strategies were effective. When asked whether a respondent's center perceives that tobacco smoking should be a deciding factor in destination therapy evaluations, nearly a third (15, 32%) responded in the affirmative. CONCLUSION: While significant overlap exists among centers regarding treatments used for smoking cessation with left ventricular assist device patients, the most common treatments are not thought to be effective. While the current recommendations require tobacco smoking cessation in only bridge-to-transplant patients and not destination therapy patients, a number of centers disagree with the national guidelines and believe smoking should be prohibited in both populations.

Winter LVAD implantation is associated with adverse clinical outcomes.

BACKGROUND: The seasonal variation of incidence and severity of heart failure is well known. However, the impact of seasonal variation on clinical outcomes following left ventricular assist device (LVAD) implantation remains unknown. METHODS: We retrospectively reviewed consecutive patients who received LVAD implantation between January 2014 and December 2016 along with their first year of post-implant outcomes. Clinical outcomes were compared between those with winter LVAD implantation (between October and March) and those with non-winter LVAD implantation. RESULTS: 168 patients with a median age of 57 years and 130 males were included. There was no seasonal difference in the number of LVAD implantations. One-year survival free from major adverse events was significantly lower in the winter implant group (n = 88) compared to the non-winter group (n = 80) (44% vs 61%) with an adjusted hazard ratio of 1.81 (95% confidence interval 1.11-2.90, p = 0.014), largely due to a higher rate of heart failure readmission in the winter implant patients (incidence rate ratio 2.29, 95% confidence interval 0.89-5.84). CONCLUSION: Patients who underwent LVAD implantation during the winter season had a higher heart failure readmission rate. A detailed mechanism and therapeutic strategy given our findings warrant further investigation.

Pulmonary hypertension and mitral regurgitation in an infant with an anatomically normal mitral valve.

A full-term, female presented on her date of birth with severe pulmonary hypertension (PH) and mitral regurgitation (MR), requiring veno-arterial extracorporeal membrane oxygenation. After the treatment, her PH and MR were resolved with no anatomic abnormality present. We propose a positive feedback loop of PH causing right ventricular dilation and interventricular septal shifts, worsening MR, and elevated left atrial, and potentially pulmonary, pressures.

Impact of plasma volume status on mortality following left ventricular assist device implantation.

Worsening systemic congestion is often the central trigger of hospitalization in patients with heart failure. However, accurate assessment of congestion is challenging. The prognostic impact of systemic congestion following durable continuous-flow left ventricular assist device (LVAD) implantation remains unknown. Consecutive patients who received durable continuous-flow LVAD implantation between January 2014 and June 2017 and were followed for 1 year were included. The association of preoperative plasma volume status, which was calculated using patients' body weight and hematocrit and expressed as a deviation from ideal plasma volume, with 1-year mortality following LVAD implantation was investigated. In total, 186 patients (median 57 years and 138 males) were included. Baseline plasma volume status was -30.1% (-37.1%, -19.4%) on median. Eighty-eight patients (47%) had higher plasma volume status (>-29.8%), and their 1-year survival was significantly lower than those without (67% vs. 87%, P = .001). High plasma volume status was an independent predictor of 1-year death with an adjusted hazard ratio of 4.52 (95% confidence interval 1.52-13.5). Baseline systemic congestion, as defined by the high plasma volume status, was associated with higher mortality following durable continuous-flow LVAD implantation. The implication of improving preoperative plasma volume remains an area of needed investigation.

Congenitally Abnormal Aortic Valve Causing Coronary Obstruction and Cardiac Arrest in Infancy.

Many instances of coronary artery anomalies are documented in the literature; however, the detection and treatment of an asymmetric, large aortic cusp causing obstruction of a coronary ostium in a symptomatic infant remains unreported. We present a case of a 2-month-old infant with an enlarged right coronary cusp obstructing the left coronary ostium, requiring emergent repair by relocating the left coronary button and reconstructing the sinus of Valsalva with autologous pericardium. This procedure preserved native aortic valve function, and the child remains asymptomatic months after discharge.

Outcomes From Three Decades of Infant and Pediatric Heart Transplantation.

Infants are a unique transplant population due to a suspected immunologic advantage, in addition to differences in size and physiology. Consequently, we expect infants to have significantly different diagnoses, comorbidities, and outcomes than pediatric transplant recipients. In this study, we compare patterns and trends in pediatric and infant heart transplantation during three decades. The United Network for Organ Sharing (UNOS) database was queried for transplants occurring between January 1990 and December 2018. Patients were categorized as pediatric (1-17) or infant (0-1). Congenital heart disease (CHD) primary diagnoses have increased from 37% to 42% in pediatric patients (p = 0.001) and decreased from 80% to 61% in infants during the 1990s and 2010s (p < 0.001). Those with CHD had worse outcomes in both age groups (p < 0.001). Infants who underwent ABO-incompatible transplants had similar survival as compared to those with compatible transplants (p = 0.18). Overall, infants had better long-term survival and long-term graft survival than pediatric patients; however, they had worse short-term survival (p < 0.001). Death due to rejection or graft failure was less likely in infants (p = 0.034). However, death from infection was over twice as common (p < 0.001). In summary, pediatric and infant heart transplant recipients differ in diagnoses, comorbidities, and outcomes, necessitating different care for these populations.

Perioperative improvement in serum albumin level in patients with left ventricular assist device.

BACKGROUND: The negative impact of baseline hypoalbuminemia on clinical outcome following left ventricular assist device (LVAD) implantation is well known. However, the implications of perioperative change in serum albumin levels on post-LVAD outcomes remain uninvestigated. METHODS: Among consecutive patients with baseline serum albumin <3.5 g/dl who received durable LVAD implantation between April 2014 and August 2017 and were followed for 1 year, the impact of perioperative change in serum albumin level from baseline to 3 months post-LVAD on the incidence of adverse events was investigated. RESULTS: Sixty-eight patients (median 60 years and 69% male) were included. Serum albumin change was an independent predictor of the occurrence of adverse events with an adjusted hazard ratio of 0.32 (95% confidence interval, 0.13-0.78) and a cutoff change of 0.7 g/dl. Those with albumin increase >0.7 g/dl had higher 1-year freedom from adverse events (45% vs. 14%, p = .008), dominantly due to lower incidence of death or sepsis compared with those without (p < .05 for both). CONCLUSION: Among those with baseline hypoalbuminemia, a considerable perioperative increase in serum albumin levels following LVAD implantation was associated with lower mortality and morbidity. The implication of aggressive nutrition intervention on LVAD patients is the next concern.