Perspective on AHFTC Specialty by Women in Heart Transplant and MCS (WiTMCS).

BACKGROUND: The advanced heart failure (HF) and transplant cardiology specialty has seen a decrease in applicants seeking training in the field. Data are needed to identify principal reform areas to generate and maintain interest in the field for sustainability. METHODS: Women in Transplant and Mechanical Circulatory support conducted a survey across their membership group investigating the barriers to attracting new talent and areas that need reform to improve the status of the specialty. A Likert scale was used to assess various perceived barriers to attracting new trainees and reform needed to improve the specialty. RESULTS: A total of 131 women physicians in transplant and mechanical circulatory support responded to the survey. Five principal areas in need of reform were identified: need for practice model variety (86.9%), inadequate compensation for non-revenue value unit activities and total compensation (86.4% and 79.1%, respectively), challenging work-life balance (78.5%), need for curriculum reform and specialized pathways (73.1% and 65.4%, respectively), and exposure during general cardiology fellowship (65.1%). CONCLUSION: Given the increasing number of patients with HF and the increased demand for more HF specialists, reform is needed to restructure the 5 areas identified in our survey to increase interest in the field of advanced HF and transplant cardiology and maintain the current talent.

The Impact of Kinlessness on Older Adults with Advanced Heart Failure.

Markers of social health, including kinlessness, social isolation and loneliness, have important implications for quality of life and health for older adults. As the population ages, there is a growing cohort of kinless older adults without living partners or children, particularly among disadvantaged groups. Kinlessness has been associated with worse mental and physical health, significant unmet care needs, increased risk of dementia, higher rates of long-term placement, and higher mortality rates than those for patients with kin. Although other markers of social health have been studied in patients with heart failure, little is known about kinlessness in this population of patients. This review outlines the data on kinlessness and its impact on patients' outcomes, and it proposes novel interventions to mitigate its effects.

Perceived Gaps in Knowledge for the Advanced Heart Failure and Transplant Cardiology Fellow: the Results of a National Needs-Assessment Survey.

BACKGROUND: The field of Advanced Heart Failure and Transplant Cardiology has evolved greatly since it was first established. We sought to elicit program directors' and fellows' viewpoints on potential curricular deficits so we can better meet the educational goals of current and future fellows. METHODS AND RESULTS: We surveyed advanced heart failure and transplant cardiology program directors and fellows concerning their perceptions of the current adequacy of training and their desire for additional training needed to achieve medical competency in advanced heart failure and transplant cardiology at their institutions, as defined by the 2017 ACC Advanced Training Statement. Survey results identified key competencies deemed to be inadequately addressed during training and those in which a moderate or significant additional amount of training was desired. These competencies were identified within the 4 main domains of the fellowship: heart failure, pulmonary hypertension, mechanical circulatory support, and heart transplantation. CONCLUSIONS: This study highlights key medical-knowledge competencies that are inadequately addressed by current fellowship training in advanced heart failure and transplant cardiology. Fellowship programs should develop curricula that focus on the integration of these competencies into training to ensure that fellows are well equipped to care for patients.

Antithrombotic Strategies with Left Ventricular Assist Devices.

Long-term outcomes of patients with advanced heart failure treated with durable left ventricular assist devices (LVADs) have been augmented due to improved durability and hemocompatibility on the backbone of pump engineering enhancements. The incidence of hemocompatibility-related adverse events (pump thrombosis, stroke and non-surgical bleeding events) are device-specific and vary by type of engineered pump. A fully magnetically levitated rotor containing LVAD in concert with use of antithrombotic therapy has successfully overcome an increased risk of thrombosis albeit with only modest reduction in bleeding events. Modifications to antithrombotic strategies have focused on reduced dose vitamin K antagonist use or use of direct oral anticoagulants with demonstration of safety, and progress in reduction of mucosal bleeding episodes with elimination of antiplatelet agents. This review outlines the current landscape of advances in anticoagulation management in LVAD patients, highlighting the need for ongoing research and cautious application of emerging therapies and technologies.

Clonal Hematopoiesis of Indeterminate Potential and Long-term Outcomes in Heart Transplantation.

BACKGROUND: Clonal hematopoiesis of indeterminate potential (CHIP) mutations, a trait of aging, has been associated with the progression of cardiovascular disease and the development of malignancy. Uncertainty prevails regarding a robust association between CHIP and heart-transplantation (HT) outcomes. OBJECTIVES: To determine the prevalence of CHIP mutations in HT and their association with long-term outcomes, including cardiac allograft vasculopathy (CAV), graft failure, malignancy, and all-cause mortality. METHODS: We conducted a mixed retrospective-prospective observational study of HT recipients with targeted sequencing for CHIP mutations (variant allele frequency [VAF] of ≥ 2%). The primary composite outcome was the first occurrence of CAV grade ≥ 2, graft failure, malignancy, cardiac retransplantation, or all-cause death. Secondary outcomes were the individual components of the composite primary outcome. Sensitivity analyses with base-case and extreme scenarios were performed. RESULTS: Among 95 HT recipients, 30 had CHIP mutations (31.6%). DNMT3A mutations were most common (44.7%), followed by PPM1D (13.2%), SF3B1 (10.5%), TET2 (7.9%), and TP53 (7.9%). The only significant independent predictor of CHIP was age at enrollment or age at transplantation. After multivariable adjustment, CHIP mutations were not associated with the primary outcome, which occurred in 44 (46.3%) patients (HR = 0.487; 95% CI:0.197-1.204; P = 0.119), nor were they associated with mlalignancy alone, or death. CONCLUSION: We demonstrated no association between CHIP mutations and post-transplant outcomes, including CAV, graft failure, malignancy, and all-cause mortality. In line with previously published data, our analysis provides additional evidence about the lack of clinical value of using CHIP mutations as a biomarker for surveillance in outcomes after HT.

Exploring suitability to electrical storm ablation in patients in waiting list for heart transplantation: A single center experience.

Electrical storm (ES) is among the most fearsome events in patients in waiting list for heart transplantation (HT) and catheter ablation (CA) demonstrated to be effective in reduce the arrhythmic burden. However, selection criteria for CA suitability in this specific population have never been addressed before. We retrospectively enrolled 36 patients (mean age 51 ± 8 years; 83% men) waiting HT referred to our department for ES resistant to antiarrhythmic drugs and percutaneous stellate ganglion blockade. Twenty patients were judged suitable for VT ablation according to specific criteria including absence of increased arrhythmic burden secondary to volume overload and hemodynamic decompensation; expected CA outcome favorable due to etiology of the cardiomyopathy, no need for coronary revascularization and technical feasibility of the procedure. The pre-emptive use of mechanical circulatory supports (MCS) were discussed integrating the PAINESD score with additional clinical and hemodynamic parameters. Acute procedural success was accounted in 85% of cases with only two major complications. The CA group reported lower length of in-hospital stay after CA suitability evaluation (56 ± 17 vs. 131 ± 64 days, p = .004). Furthermore, at a mean follow-up of 703 ± 145 days, this group showed reduction of ventricular arrhythmia (VA) recurrence leading to implantable cardioverter defibrillator shock (4 vs. 8, p = .051) and underwent HT with a lower level of urgency (0 vs. 6 patients needed for UNOS1 status upgrade). Respectively, one patient of the CA group and two patients of the conservative group died (p = .839). At the end of follow-up, eight patients underwent heart transplantation (p = .964) while four patients underwent Left Ventricular Assist device (LVAD) implantation (p = .440). This pilot study should be a proof for further studies exploring CA of VAs as a possible bridge therapy to HT.

Programmatic approach to patients with advanced ischemic cardiomyopathy: Integrating microaxial support into strategies for the modern era.

Patients with advanced ischemic cardiomyopathy manifesting as left ventricular dysfunction exist along a spectrum of severity and risk, and thus decision-making surrounding optimal management is challenging. Treatment pathways can include medical therapy as well as revascularization through percutaneous coronary intervention or coronary artery bypass grafting. Additionally, temporary and durable mechanical circulatory support, as well as heart transplantation, may be optimal for select patients. Given this spectrum of risk and the complexity of treatment pathways, patients may not receive appropriate therapy given their perceived risk, which can lead to sub-satisfactory outcomes. In this review, we discuss the identification of high-risk ischemic cardiomyopathy patients, along with our programmatic approach to patient evaluation and perioperative optimization. We also discuss our strategies for therapeutic decision-making designed to optimize both short- and long-term patient outcomes.

Multicenter evaluation of left ventricular assist device implantation with or without ECMO bridge in cardiogenic shock.

BACKGROUND: The efficacy of extracorporeal membrane oxygenation (ECMO) as a bridge to left ventricular assist device (LVAD) remains unclear, and recipients of the more contemporary HeartMate 3 (HM3) LVAD are not well represented in previous studies. We therefore undertook a multicenter, retrospective study of this population. METHODS AND RESULTS: INTERMACS 1 LVAD recipients from five U.S. centers were included. In-hospital and one-year outcomes were recorded. The primary outcome was the overall mortality hazard comparing ECMO versus non-ECMO patients by propensity-weighted survival analysis. Secondary outcomes included survival by LVAD type, as well as postoperative and one-year outcomes. One hundred and twenty-seven patients were included; 24 received ECMO as a bridge to LVAD. Mortality was higher in patients bridged with ECMO in the primary analysis (HR 3.22 [95%CI 1.06-9.77], p = 0.039). Right ventricular assist device was more common in the ECMO group (ECMO: 54.2% vs non-ECMO: 11.7%, p < 0.001). Ischemic stroke was higher at one year in the ECMO group (ECMO: 25.0% vs non-ECMO: 4.9%, p = 0.006). Among the study cohort, one-year mortality was lower in HM3 than in HeartMate II (HMII) or HeartWare HVAD (10.5% vs 46.9% vs 31.6%, respectively; p < 0.001) recipients. Pump thrombosis at one year was lower in HM3 than in HMII or HVAD (1.8% vs 16.1% vs 16.2%, respectively; p = 0.026) recipients. CONCLUSIONS: Higher mortality was observed with ECMO as a bridge to LVAD, likely due to higher acuity illness, yet acceptable one-year survival was seen compared with historical rates. The receipt of the HM3 was associated with improved survival compared with older generation devices.

Pre-operative pectoralis muscle area index is associated with biomarkers of inflammation and endotoxemia and predicts clinical outcomes after left ventricular assist device implantation: A cohort study.

BACKGROUND: Pre-left ventricular assist device (LVAD) pectoralis muscle assessment, an estimate of sarcopenia, has been associated with postoperative mortality and gastrointestinal bleeding, though its association with inflammation, endotoxemia, length-of-stay (LOS), and readmissions remains underexplored. METHODS: This was a single-center cohort study of LVAD patients implanted 1/2015-10/2018. Preoperative pectoralis muscle area was measured on chest computed tomography (CT), adjusted for height squared to derive pectoralis muscle area index (PMI). Those with PMI in the lowest quintile were defined as low-PMI cohort; all others constituted the reference cohort. Biomarkers of inflammation (interleukin-6, adiponectin, tumor necrosis factor-α [TNFα]) and endotoxemia (soluble (s)CD14) were measured in a subset of patients. RESULTS: Of the 254 LVAD patients, 95 had a preoperative chest CT (median days pre-LVAD: 7 [IQR 3-13]), of whom 19 (20.0%) were in the low-PMI cohort and the remainder were in the reference cohort. Compared with the reference cohort, the low-PMI cohort had higher levels of sCD14 (2594 vs. 1850 ng/mL; p = 0.04) and TNFα (2.9 vs. 1.9 pg/mL; p = 0.03). In adjusted analyses, the low-PMI cohort had longer LOS (incidence rate ratio 1.56 [95% confidence interval 1.16-2.10], p = 0.004) and higher risk of 90-day and 1-year readmissions (subhazard ratio 5.48 [1.88-16.0], p = 0.002; hazard ratio 1.73 [1.02-2.94]; p = 0.04, respectively). CONCLUSIONS: Pre-LVAD PMI is associated with inflammation, endotoxemia, and increased LOS and readmissions.

Cardiac magnetic resonance in advanced heart failure.

Heart failure (HF) is a chronic and progressive disease that often progresses to an advanced stage where conventional therapy is insufficient to relieve patients' symptoms. Despite the availability of advanced therapies such as mechanical circulatory support or heart transplantation, the complexity of defining advanced HF, which requires multiple parameters and multimodality assessment, often leads to delays in referral to dedicated specialists with the result of a worsening prognosis. In this review, we aim to explore the role of cardiac magnetic resonance (CMR) in advanced HF by showing how CMR is useful at every step in managing these patients: from diagnosis to prognostic stratification, hemodynamic evaluation, follow-up and advanced therapies such as heart transplantation. The technical challenges of scanning advanced HF patients, which often require troubleshooting of intracardiac devices and dedicated scans, will be also discussed.

Remote monitoring of severe heart failure.

Patients with advanced heart failure, due to the instability of their clinical conditions, need close surveillance to avoid dangerous exacerbations or sudden events. Digital technology can be of great help in this contest, thanks to remote monitoring, made possible with the use of wearable or implantable instruments. The latter are currently generally inserted inside defibrillators or resynchronization systems, or inserted inside the pulmonary circulation for monitoring pulmonary pressure. Parameters such as thoracic impedance, physical activity, heart rate variability, atrial and ventricular arrhythmias, blood pressure, and O2 saturation can be controlled remotely. The data relating to the actual benefit in terms of avoidable events (death and hospitalizations) are not definitive, but certainly from an organizational point of view, the benefit is evident, both on the part of the patient and of the organization of care. The latter, provided in the form of televisits, requires a re-modulation of the system, making use of trained personnel, a well-structured network, and digital technologies (platforms, electronic health records) that are not yet perfectly developed. The evolution of the solutions offered by artificial intelligence guarantees a rapid and progressive refinement of telemedicine in this sector.

Sex and Gender-related Disparities in Clinical Characteristics and Outcomes in Heart Transplantation.

PURPOSE OF REVIEW: Limited research has been conducted on sex disparities in heart transplant (HT). The aim of this review is to analyse the available evidence on the influence of sex and gender-related determinants in the entire HT process, as well as to identify areas for further investigation. RECENT FINDINGS: Although women make up half of the population affected by heart failure and related mortality, they account for less than a third of HT recipients. Reasons for this inequality include differences in disease course, psychosocial factors, concerns about allosensitisation, and selection or referral bias in female patients. Women are more often listed for HT due to non-ischaemic cardiomyopathy and have a lower burden of cardiovascular risk factors. Although long-term prognosis appears to be similar for both sexes, there are significant disparities in post-HT morbidity and causes of mortality (noting a higher incidence of rejection in women and of malignancy and cardiac allograft vasculopathy in men). Additional research is required to gain a better understanding of the reasons behind gender disparities in eligibility and outcomes following HT. This would enable the fair allocation of resources and enhance patient care.

Bias in team decision-making for advanced heart failure therapies: model application.

Bias in advanced heart failure therapy allocation results in inequitable outcomes for minoritized populations. The purpose of this study was to examine how bias is introduced during group decision-making with an interprofessional team using Breathett's Model of Heart Failure Decision-Making. This was a secondary qualitative descriptive analysis from a study focused on bias in advanced heart failure therapy allocation. Team meetings were recorded and transcribed from four heart failure centers. Breathett's Model was applied both deductively and inductively to transcripts (n = 12). Bias was identified during discussions about patient characteristics, clinical fragility, and prior clinical decision-making. Some patients were labeled as "good citizens" or as adherent/non-adherent while others benefited from strong advocacy from interprofessional team members. Social determinants of health also impacted therapy allocation. Interprofessional collaboration with advanced heart failure therapy allocation may be enhanced with the inclusion of patient advocates and limit of clinical decision-making using subjective data.

Quality of Life in Palliative Care: A Systematic Meta-Review of Reviews and Meta-Analyses.

Background: The area of palliative care is a setting in which the evaluation of the quality of life (QoL) is fundamental. However, the topic has been covered from many different points of view, and there is a lack of comprehensive synthesis of the evidence drawn from the available literature. Objective: We carried out a meta-review of all available systematic reviews and meta-analyses that have dedicated part or most of the investigation to the assessment of QoL in palliative care to provide the most updated and comprehensive depiction of all available information about measurement and intervention aimed at improving QoL in palliative care. Methods: A meta-review of all recent (5 years) available systematic reviews and meta-analyses on "palliative care" and "quality of life" was carried out. The quality of the extracted studies was assessed with the AMSTAR scale. Results: The search extracted 24 systematic reviews, 14 systematic reviews followed by a meta-analysis on a subset of data, and 2 meta-analyses. In many studies, the investigation of QoL represented a secondary or even marginal outcome. In general, the results supported the efficacy of palliative care in terminal patients or patients with a permanent disability. However, the quality of the studies had a strong influence on the chance that some improvement in QoL was found in relation to palliative care. Studies of lower quality were more likely to report some efficacy of palliative care than studies with better quality. Conclusion: The investigation of QoL in palliative care is understudied. In many studies, QoL is a secondary outcome, and there is some tendency to use a disparate range of tools to measure it, whose reliability and validity should still be established in some groups of patients.

Changes in Kidney Function After Diagnosis of Advanced Heart Failure.

BACKGROUND: Kidney function and its association with outcomes in patients with advanced heart failure (HF) has not been well-defined. METHODS AND RESULTS: We conducted a retrospective cohort study comprising all adult residents of Olmsted County, Minnesota, with HF who developed advanced HF from 2007 to 2017. Patients were grouped by estimated glomerular filtration rate (eGFR) at advanced HF diagnosis using the 2021 Chronic Kidney Disease Epidemiology Collaboration equation. A linear mixed effects model was fitted to assess the relationship between development of advanced HF and longitudinal eGFR trajectory. A total of 936 patients with advanced HF (mean age 77 years, 55% male, 93.7% White) were included. Twenty-two percent of these patients had an eGFR of <30 at advanced HF diagnosis, 22% had an eGFR of 30-44, 23% had an eGFR of 45-59, and 32% had an eGFR of ≥60 mL/min/1.73 m2. The eGFR decreased faster after advanced HF (7.6% vs 10.9% annual decline before vs after advanced HF), with greater decreases after advanced HF in those with diabetes and preserved ejection fraction. An eGFR of <30 mL/min/1.73 m2 was associated with worse survival after advanced HF compared with an eGFR of ≥60 mL/min/1.73 m2 (adjusted hazard ratio 1.30, 95% confidence interval 1.07-1.57). CONCLUSIONS: eGFR deteriorated faster after patients developed advanced HF. An eGFR of <30 mL/min/1.73 m2 at advanced HF diagnosis was associated with higher mortality.

Beyond Stage C: Considerations in the Management of Patients With Heart Failure Progression and Gaps in Evidence.

Despite treatment with contemporary medical therapies for chronic heart failure (HF), there has been an increase in the prevalence of patients progressing to more advanced disease. Patients progressing to and living at the interface of severe stage C and stage D HF are underrepresented in clinical trials, and there is a lack of high-quality evidence to guide clinical decision making. For patients with severe HF phenotypes, the medical therapies used for patients with less advanced stages of illness are often no longer tolerated or provide inadequate clinical stability. The limited data on these patients highlights the need to increase formal research characterizing this high-risk population. This review summarizes existing clinical trial data and incorporates our considerations for approaches to the medical management of patients advanced "beyond stage C" HF.

Gastrointestinal bleeding in recipients of left ventricular assist devices-a systematic review.

The twenty-first century has revolutionized the management of congestive heart failure with the widespread use of left ventricular assist devices and other treatment modalities that improve morbidity and mortality after the failure of medical management. These novel devices come with significant side effects. One of the most common side effects of left ventricular assist devices is the increased frequency of lower gastrointestinal bleeding compared to heart failure patients without left ventricular assist devices. Multiple etiologies of recurrent gastrointestinal bleeding in such patients have been studied. The decreased amount of von Willebrand factor polymers is now recognized as one of the most common causes of increased incidence of gastrointestinal bleeding in patients with left ventricular assist devices alongside increased arteriovenous malformations. Multiple treatment modalities have been identified to prevent and treat gastrointestinal bleeding in these patients. Since the use of left ventricular assist devices is becoming more prevalent in patients with advanced heart failure, we decided to conduct this systematic review. The article summarizes the incidence, pathophysiology, and management of lower gastrointestinal bleeding in patients with left ventricular assist devices.

Heart transplantation in end-stage heart failure secondary to cardiac sarcoidosis: an updated systematic review.

The prevalence of cardiac sarcoidosis is increasing with improved cardiac imaging and may lead to severe heart failure, cardiomyopathy, and arrhythmias that warrant heart transplant consideration. This study aimed to evaluate the outcomes of heart transplantation in sarcoidosis. We systematically searched PubMed/MEDLINE, EMBASE and Cochrane Library following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. We identified 15 articles that examined patients with cardiac sarcoidosis. The study aimed to evaluate the outcomes of heart transplantation in cardiac sarcoidosis. We systematically searched EMBASE, PubMed/MEDLINE, and Cochrane Library following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. We identified 15 studies that examined 1075 patients with cardiac sarcoidosis who underwent heart transplantation. A total of five studies reported individual patient data. Forty-two patients have been pooled for further analysis. There were 22 male patients, 14 female patients, and 7 patients whose gender was not reported. Among these patients, 10 patients had concomitant pulmonary sarcoidosis at the time of diagnosis. The mean survival was reported for all 42 patients. The mean survival in months was 71.4 months, with a range of 2 days to 288 months. Three patients died of graft failure, 2 patients from septic shock, 2 patients from pneumonia, 1 patient from cervical cancer, and 1 patient from sudden cardiac death. One patient developed a malignant arrythmia in the setting of CMV myocarditis post-heart transplant. Sarcoidosis recurrence after heart transplant was reported in 3 of 30 patients..Patients with cardiac sarcoidosis have shown to have favorable outcomes after heart transplant. Despite these outcomes, some centers still hesitate to pursue heart transplant for CS patients. Carefully selected patients with advanced-stage heart failure due to cardiac sarcoidosis have encouraging outcomes after transplantation. Further studies will be needed to evaluate the outcomes of heart transplantation in sarcoidosis.

Theoretical considerations for a left atrial pump in heart failure with preserved ejection fraction.

Heart failure with preserved ejection fraction (HFpEF) is a heterogenous group of disorders, unified by findings of elevated left atrial and left ventricular filling pressures in the setting of normal systolic function. Medical therapies for HFpEF patients are markedly limited, and these patients are often unable to tolerate conventional left ventricular assist device therapies because of small chamber size. The Synergy System (CircuLite, Inc., Saddle Brook, NJ) was a micropump-based form of mechanical circulatory support in which flow derived from the left atrium was delivered to the subclavian artery. In this review, we discuss the potential role of the Synergy left atrial pump to address the hemodynamic derangements of HFpEF.

Socioeconomic status and in-hospital outcomes for patients undergoing heart transplantation or ventricular assist device implantation.

INTRODUCTION: Although lower socioeconomic status (SES) has been associated with worse in-hospital outcomes among patients with heart failure, the in-hospital outcomes for patients undergoing durable Left Ventricular Assist Device (LVAD) implantation or Heart Transplantation (HT) based on SES have not been well characterized. METHODS: We analyzed data from the National Inpatient Sample of hospitalizations between January 2016 and December 2020 of patients aged 18 and over who underwent a HT or newly implanted LVAD. Quartile classification of the median household income of the patient's residential zip code was used to estimate SES. Multivariable analyses with logistic and linear regression were used to evaluate the effects of SES on inpatient outcomes including inpatient mortality, length of stay, and key inpatient complications. RESULTS: A total of 16,265 weighted hospitalizations for new LVAD implantation and 14,320 weighted hospitalizations for HT were identified. In multivariable analysis, among patients undergoing HT or LVAD implantation respectively, there were no significant differences between the lowest and highest SES quartiles among important in-hospital outcomes including length of stay (adj B-coeff .56, (-3.59)-(4.71), p = .79 and adj B-coeff 2.40, (-.21)-(5.02), p = .07) and mortality (aOR 1.02, .61-1.70, p = .94 and aOR 1.08, .72-1.62, p = .73). There were also no differences based on SES quartile in important inpatient complications including stroke and cardiac arrest. CONCLUSION: In this analysis from the National Inpatient Sample, we demonstrate that SES, evaluated by median zip code income, was not associated with important in-hospital metrics including mortality and length of stay among patients undergoing LVAD or HT.