Impact of heart transplant allocation change on competing waitlist outcomes among listing strategies.

In 2018, the United Network for Organ Sharing (UNOS) adopted a 6-tier system for heart allocation which shifted patterns in listing strategies. The effects of the change on waitlist survival and transplantation rates have yet to be substantiated by analysis of competing outcomes among various listing strategies. This study included all adult patients listed for first-time heart transplantation in UNOS between 10/17/15 and 6/12/20. Clinical characteristics were compared before and after allocation change among various listing strategies: no support, inotropes, intra-aortic balloon pump, durable left ventricular assist device (LVAD), temporary VAD, and extracorporeal membrane oxygenation. Fine-Gray proportional subhazard models were used to estimate the effect of allocation change on competing waitlist outcomes-transplantation, death, or removal from waitlist-among each strategy. During the study period, there were 17 422 patients listed for heart transplantation. Among each listing strategy, clinical characteristics were similar before and after allocation change. Subhazard models demonstrated reduced risk for waitlist mortality (p < .001) among each strategy except temporary VAD and increased transplantation rates (p < .001) among each strategy except for durable LVAD. These results validate the association of the new allocation system on waitlist outcomes across listing strategies.

A Review of Inotropes and Inopressors for Effective Utilization in Patients With Acute Decompensated Heart Failure.

ABSTRACT: Inotropes and inopressors are often first-line treatment in patients with cardiogenic shock. We summarize the pharmacology, indications, and contraindications of dobutamine, milrinone, dopamine, norepinephrine, epinephrine, and levosimendan. We also review the data on the use of these medications for acute decompensated heart failure and cardiogenic shock in this article.

Successful Pregnancy After Left Ventricular Assist Device Explantation for Myocardial Recovery.

A 36 year old woman with history of heart failure and left ventricular assist device (LVAD) implantation, with subsequent explantation after myocardial recovery, presented for management of preconception counseling and subsequent pregnancy. To our knowledge, this case represents the first documented successful pregnancy after LVAD explantation. Management details are provided, and relevant literature is reviewed.

Calcified amorphous tumor attached to the membranous septum: a rare clinical entity.

We report a rare case of a pedunculated calcified amorphous tumor (CAT) of the left ventricle attached by a stalk to the membranous septum in a 74-year-old woman who presented with a cerebrovascular accident. We believe this is the first report of a CAT attached to the membranous septum.

Echocardiographic Parameters and Outcomes in Methamphetamine-Associated Heart Failure: A Propensity Score-Weighted Analysis.

Background: Methamphetamines are a common cause of systolic heart failure (HF). There are limited data on the prognosis associated with hospitalizations for decompensated HF in the setting of methamphetamine use. We aimed to evaluate patient characteristics and outcomes among patients admitted with decompensated HF who had positive drug screens for amphetamines as well as to determine whether any parameters from transthoracic echocardiogram (TTE) can predict outcomes in this population. Methods: This was a retrospective cohort study of consecutive adult patients admitted to the Loma Linda Medical Center who had an active hospital problem of acute on chronic systolic (or systolic and diastolic) HF from 2013 to 2018. Electronic medical records were mined for relevant patient data. Methamphetamine-associated heart failure (MethHF) group was defined as those with an admission urine drug screen (UDS) that was positive for methamphetamines, whereas non-MethHF was defined by patients with negative methamphetamine on UDS or UDS was not done on physician's discretion. The primary outcomes of the study were 30-day composite outcome (defined as combined all-cause readmission and all-cause mortality), 365-day all-cause mortality, and length of stay (LOS). Propensity score weighting for these outcomes was performed using demographics, laboratory and clinical variables, and left ventricular ejection fraction (LVEF) as covariates. TTE parameters from presentation were also evaluated to determine if any had prognostic implications. Results: A total of 1,655 patients were included (101 patients with positive urine methamphetamine and 1,554 patients without). Patients with MethHF were younger, more likely to be male, had fewer comorbidities, had lower LVEF, and were more likely to have right ventricular systolic dysfunction. In propensity-weighted analyses, there were no significant differences in LOS, 30-day composite outcome, or 365-day mortality between the MethHF and non-MethHF group in (P > 0.05 for all). Presence of at least moderate tricuspid valve regurgitation (TR) was the only TTE predictor of 30-day composite outcome (odds ratio (OR) = 4.67, 95% confidence interval (CI): 1.5 - 14.50, P < 0.01) and 365-day mortality (OR = 4.67, 95% CI: 1.5 - 14.50, P < 0.01) in the MethHF group. Conclusion: Patients with MethHF admitted for decompensated HF had similar outcomes compared to non-MethHF after adjusting for baseline characteristics. TR is the only TTE value to predict outcomes in this population.

Multidisciplinary Approach to Hemodynamic Management During High-Risk Ventricular Tachycardia Ablation.

Percutaneous ventricular assist devices have been used for high-risk ventricular tachycardia ablation when hemodynamic decompensation is expected. Utilizing a case example, we present our experience with development of a coordinated, team-based approach focused on periprocedural management of patients with high-risk ventricular tachycardia. (Level of Difficulty: Advanced.).

A Case Report of Loperamide-Induced Ventricular Storm.

Loperamide is an easily accessible antidiarrheal medication. Unlike other medications in its class, loperamide is unique in that it causes euphoria at supratherapeutic levels due to its effect on opioid receptors. Unfortunately, with its growing abuse potential also comes increasing reports of cardiotoxicity including prolonged QT, torsades de pointes, and sudden cardiac death. We report a case of a 29-year-old female who presented with unstable arrhythmia that further progressed into electrical storm in the setting of loperamide toxicity. Due to its growing popularity and availability, it is important for clinicians to understand loperamide's mechanisms for causing toxicity as well as how to appropriately treat its complications.

Echocardiography-Based Hemodynamic Monitoring Use on Inpatients Listed for Heart Transplantation Under 2018 Allocation Policy in United States.

BACKGROUND: One notable change to the 2018 United Network for Organ Sharing listing criteria was to allow for the use of noninvasive hemodynamic monitoring for inpatients listed as status 3 for heart transplantation. We wanted to explore the feasibility of performing daily focused echocardiograms in place of invasive monitoring in this population. METHODS: On retrospective chart review of inpatients listed for transplantation at our institution, 8 patients in the invasive monitoring group listed as status 1A (October 2016 to October 2018) and 9 patients in the echocardiographic group listed as status 3 (October 2018 to February 2020) were identified. RESULTS: There were no significant differences between the 2 cohorts in the average measured/estimated right atrial, pulmonary artery systolic, and wedge pressures, although the echo cohort had lower cardiac index (P = .001). There were 2 patients with positive blood cultures treated with Swan exchange in Swan cohort and a total of 14 Swan exchanges. There were no infections in the noninvasive group. CONCLUSION: We present our experience with the use of noninvasive daily hemodynamic assessment using focused echocardiograms to manage patients undergoing heart transplantation listing as status 3 under the new United Network for Organ Sharing allocation system. This approach appears safe and feasible; however, it requires validation in larger cohorts.

Trial of Oral Diuretics Prior to Discharge Is Not Associated With Improved Outcomes in Decompensated Heart Failure.

BACKGROUND: Current heart failure guidelines recommend transition of intravenous (IV) diuretics to oral > 24 h prior to hospital discharge. The aim of this study was to determine whether transition to oral diuretics prior to discharge in patients hospitalized with decompensated systolic heart failure (SHF) was associated with improved 30-day events. METHODS: This was a retrospective cohort study, in which adults admitted to the Loma Linda Medical Center for 3 - 14 days with a primary discharge diagnosis of acute on chronic SHF were included. Mortality data were obtained from the National Death Index, while readmission only to our facility was included. The t-test and Chi-square test were used for analyses. RESULTS: A total of 314 patients were studied. Patients who were managed with guideline-recommended trial of oral diuretics, and patients who continued to receive IV diuretics on the last full hospital day were overall similar in baseline characteristics. Patients who received oral diuretics on the day prior to discharge had longer length of stay, less weight loss, were discharged on lower diuretic doses (all P < 0.05), and had similar outcomes of 30-day readmission and 30-day hospitalization-free survival. CONCLUSIONS: The transition to oral diuretics prior to discharge in patients with decompensated SHF was not associated with improved 30-day outcomes. These results require validation in prospective trials but suggest that guideline recommendations regarding transitioning to oral diuretics prior to discharge may deserve re-evaluation.

Role of Guideline Directed Medical Therapy Doses and Optimization in Patients Hospitalized With Decompensated Systolic Heart Failure.

Despite significant advances in evidence-based treatments for heart failure with reduced ejection fraction (HFrEF), the use of guideline directed medical therapy (GDMT) at recommended doses remains suboptimal. We examine the usage and modification of inpatient GDMT and its effect on outcomes in patients hospitalized with a diagnosis of acute on chronic HFrEF between 2013 and 2018. Overall use and modification of GDMT, which included heart failure appropriate beta-blockers (BB), renin-angiotensin system inhibitors (RASi) and aldosterone blockers (MRA) during the hospitalization were collected. Target dosages were based on guideline recommendations. Primary endpoints included 30-day hospitalization-free survival and 1-year survival. Among 1,655 patients, discharge use of BB, RASi, and MRA was 73.4%, 55.9% and 13.8%, respectively. Upon discharge, ≥50% target dose of BB, RASi, and MRA was used in 25.3%, 15.6%, and 13.7%, respectively. In multivariable analyses, there was a statistically significant improvement in 1-year survival and 30-day hospitalization-free survival in patients discharged on increasing number of medication classes optimized at ≥50% target dose (per extra medication, HR 0.74, 0.64-0.86, p <0.001, and HR 0.73, 0.62-0.86, p = 0.0002), respectively. Initiation and/or uptitration of BB and RASi was associated with improved 30-day hospitalization-free survival and 1-year survival, (HR 0.73 (0.57-0.92), p = 0.0087; HR 0.62 (0.46-0.82), p <0.001) for BB and (HR 0.77 (0.62-0.95), p <0.001; HR 0.62 (0.48-0.80), p <0.001) for RASi, respectively. In conclusion, inpatient optimization of GDMT in acute HFrEF is feasible and associated with improved 30-day hospitalization-free survival and 1-year survival.

Utility of Framingham Score for Optimizing Preoperative Evaluation Among Patients Undergoing Liver Transplant Evaluation.

BACKGROUND: Cardiac testing of candidates for liver transplant (LT) requires balancing risks and benefits of cardiac procedures. The goal of this study was to evaluate the utility of the Framingham score (FS) for optimizing preoperative risk stratification for coronary artery disease (CAD). METHODS: In this single-center retrospective study of 615 adults undergoing LT evaluation from 2016 to 2019, data of preoperative evaluation, post-LT 1-year mortality, and post-LT cardiac events were reviewed. Patients >30 years of age with normal echocardiogram underwent FS calculation. Elevated FS (≥35%) patients were triaged to undergo angiogram for CAD evaluation; FS <35% patients underwent stress testing as initial CAD evaluation. RESULTS: Of 615 patients referred for LT, 481 underwent cardiac testing. Ninety-five were excluded from the FS pathway because of age, abnormal baseline echocardiogram, or known CAD. Of the remaining 386 patients in the FS pathway, 342 had a low FS and 44 had a high FS. In patients with low FS, 90% underwent stress testing as initial test; 16% underwent invasive testing at some time. In those with elevated FS, 59% underwent invasive testing as initial test. Listing rate and posttransplant outcomes were similar between patients with low and high FS. CONCLUSION: We demonstrated the feasibility of a simple algorithmic evaluation process using FS for optimizing pre-LT risk stratification for CAD. Although exceptions to the protocol occur, the proposed protocol allows for a streamlined approach by prioritizing testing based on cardiac risk. This approach may maximize diagnostic yield while limiting invasive procedures.

Inpatient Diuretic Management of Acute Heart Failure: A Practical Review.

The inpatient treatment of acute heart failure (AHF) is aimed at achieving euvolemia, relieving symptoms, and reducing rehospitalization. Adequate treatment of AHF is rooted in understanding the pharmacokinetics and pharmacodynamics of select diuretic agents used to achieve decongestion. While loop diuretics remain the primary treatment of AHF, the dosing strategies of loop diuretics and the use of adjunct diuretic classes to augment clinical response can be complex. This review examines the latest strategies for diuretic management in patients with AHF, including dosing and monitoring strategies, interaction of diuretics with other medication classes, use adjunctive therapies, and assessing endpoints for diuretic. The goal of the review is to guide the reader through commonly encountered clinical scenarios and pitfalls in the diuretic management of patients with AHF.

Predictors of In-hospital Mortality in Cardiogenic Shock Patients on Vasoactive or Inotropic Support.

BACKGROUND: Though controversial, the short-duration in-patient use of inotropes in cardiogenic shock (CS) remain an ACC/AHA Class IIa indication, and are frequently used in the initial treatment of CS. We evaluated in-patient mortality and effect on mortality risk of commonly used vasoactive inotropic medications for the medical management of SCAI stage B and C cardiogenic shock patients in a tertiary care cardiac care unit: dobutamine, dopamine, milrinone, and norepinephrine. METHODS: We retrospectively evaluated 342 patients who received dobutamine, milrinone, dopamine, norepinephrine or a combination of these medications for SCAI stage B and C cardiogenic shock. Cox proportional hazards were used to form longitudinal mortality predictions. RESULTS: Overall in-patient mortality was 18%. Each 1 µg/kg/minute increase in dobutamine independently corresponded to a 15% increase in risk of mortality. High dose dobutamine >3 µg/kg/minute is associated with 3-fold increased risk compared to ⩽3 µg/kg/minute (P < .001). Use of milrinone, norepinephrine, and dopamine were not independently associated with mortality. CONCLUSION: We demonstrate that the overall in-hospital mortality of SCAI stage B and C cardiogenic shock patients medically managed on inotropes was not in excess of prior studies. Dobutamine was independently associated with mortality, while other vasoactive inotropic medications were not. Inotropes remain a feasible method of managing SCAI stage B and C cardiogenic shock.

Long-term outcome of Tako-tsubo cardiomyopathy.

BACKGROUND: Current data suggest an excellent outcome for patients with Tako-tsubo cardiomyopathy (TC). The objectives of this study were to evaluate the long-term outcome and the prognostic implication of thrombolysis in myocardial infarction myocardial perfusion grade (TMPG) in patients with TC. METHODS: Retrospective analysis of all patients diagnosed with TC at our hospital between 2003 and 2008. RESULTS: During the five-year period, we identified 27 patients with TC out of 1374 cases of emergent left heart catheterisation (2%). Mean follow-up was 27 ± 16 months. The majority were Caucasian (81%) female (96%), postmenopausal (96%), with a mean age of 68 ± 14 years. A precipitating stressor event was found in 74% of the patients, 30% being gastrointestinal triggers. Fourteen patients (52%) reached a combined end point of all cause death, cardiogenic shock, sudden cardiac death and rehospitalisation for cardiac reasons. TMPG was abnormal in 37% cases with no correlation with the outcome. CONCLUSIONS: The long-term outcome of patients with TC is worse than previously reported. TMPG does not correlate with the outcome in TC.

A Multidisciplinary Approach to Electrical Instability and Cardiogenic Shock in Acute Myocardial Infarction.

New cardiogenic shock classifications allow prompt recognition and management of complications of acute coronary syndrome. A 59-year-old man presented after a delayed left anterior descending coronary artery ST-segment elevation myocardial infarction in Society of Cardiovascular Angiography and Interventions stage E cardiogenic shock and ventricular tachycardia storm. He underwent revascularization of the left anterior descending artery, percutaneous left ventricular assist device bridged to permanent assist device placement, epicardial and endocardial ventricular tachycardia ablation, and iatrogenic closure of an atrial septal defect. (Level of Difficulty: Beginner.).

Aortobronchial Fistula Causing Recurrent Hemoptysis 21 Years Post-Heart Transplant.

Aortobronchial fistulae (ABF) are uncommon but potentially fatal anomalies. Patients may initially present with small volume hemoptysis, which can rapidly lead to massive hemoptysis and death if not diagnosed and intervened upon early. Diagnosis by imaging and bronchoscopy is not always conclusive; thus, a high index of suspicion is necessary to diagnose this life-threatening condition. Herein, we describe a case of a young man who had a late presentation of ABF 21 years following heart transplantation. This case illustrates the diagnostic and clinical challenge of ABF as a late sequela of cardiac transplantation and highlights the rarity of this anomaly.

Predictors of Systolic Heart Failure and Mortality Following Orthotopic Liver Transplantation: a Single-Center Cohort.

OBJECTIVES: The purpose of this study was to identify risk factors that may predict heart failure with reduced ejection fraction (HFrEF) following orthotopic liver transplantation (OLT) and associated mortality. BACKGROUND: HFrEF following OLT is a poorly understood phenomenon, reported in 3% to 7% of transplanted patients. METHODS: This is a retrospective analysis of 176 consecutive patients who underwent OLT from 2010 to 2017. Multivariate logistic regression was used to identify associations between cardiovascular risk factors and perioperative variables with post-OLT HFrEF, defined as reduction in left ventricular ejection fraction of at least 10% and left ventricular ejection fraction less than or equal to 40% with acute heart failure symptoms. Multivariate cox proportional hazards regression (with inverse probability weighting by propensity scores) was used to evaluate effects of HFrEF on 1-year mortality. RESULTS: Of the176 patients, 14% developed HFrEF with a median of 5 days. History of heart failure (OR 10.99, 2.15-56.09; P = .04) and intraoperative transfusion of greater than 11 units of packed red blood cells (OR 3.377, 1.025-11.13; P = .045) were associated with increased incidence of HFrEF. Pre-transplant hemoglobin greater than 8.5 g/dL (OR 0.252, CI 0.0954- 0.665; P = .05) was protective against HFrEF. Thirty-three percent of HFrEF group died within 1 year (HR 7.36, 2.57-21.12; P < .001). CONCLUSIONS: The incidence of acute HFrEF post-OLT is 14% and is associated with a 7-fold increase in 1-year mortality. Cirrhotic cardiomyopathy and stress-induced cardiomyopathy maybe the underlying mechanisms. Our study identified risk factors associated with post-OLT HFrEF and should provide additional guidance for risk stratification of patients undergoing OLT.

Nesiritide in the initial management of acute decompensated congestive heart failure.

BACKGROUND: In the era of evolving therapy for heart failure (HF), optimal medical therapy has become challenging. Nesiritide is being used for HF therapy but its impact is still controversial. METHODS: Prospective and randomized controlled study of 34 patients who presented to the emergency department (ED) with HF and remained symptomatic despite maximal standard therapy delivered for at least one hour. All patients had B-type natriuretic peptide BNP >100 pg/dl. Patients were randomized into Group A which received maximal standard therapy and group B which received nesiritide bolus followed by an infusion (0.01 mcg/kg/min) in addition to maximal therapy. Primary endpoints included HF hospital readmission, and hospital length of stay (LOS). Secondary endpoints included HF, cardiovascular, all-cause mortality, and adverse events. Composite risk score was designed. Results were analyzed using a logistic regression model and bootstrapping simulating approach. RESULTS: Decrease in rehospitalizations for HF was observed during the 30 days and six-month follow-up in Group B. Earlier initiation of nesiritide therapy consistently shortened hospital LOS. Group B had a decrease in 30-day mortality but not after one year. CONCLUSIONS: Acute HF patients who do not respond to maximal standard therapy appear to benefit from the early addition of nesiritide.