Comparative Analysis of Established Risk Scores and Novel Hemodynamic Metrics in Predicting Right Ventricular Failure in Left Ventricular Assist Device Patients.

BACKGROUND: Right ventricular failure (RVF) portends poor outcomes after left ventricular assist device (LVAD) implantation. Although numerous RVF predictive models have been developed, there are few independent comparative analyses of these risk models. METHODS AND RESULTS: RVF was defined as use of inotropes for >14 days, inhaled pulmonary vasodilators for >48 hours or unplanned right ventricular mechanical support postoperatively during the index hospitalization. Risk models were evaluated for the primary outcome of RVF by means of logistic regression and receiver operating characteristic curves. Among 93 LVAD patients with complete data from 2011 to 2016, the Michigan RVF score (C = 0.74 [95% CI 0.61-0.87]; P = .0004) was the only risk model to demonstrate significant discrimination for RVF, compared with newer risk scores (Utah, Pitt, EuroMACS). Among individual hemodynamic/echocardiographic metrics, preoperative right ventricular dysfunction (C = 0.72 [95% CI 0.58-0.85]; P = .0022) also demonstrated significant discrimination of RVF. The Michigan RVF score was also the best predictor of in-hospital mortality (C = 0.67 [95% CI 0.52-0.83]; P = .0319) and 3-year survival (Kaplan-Meier log-rank 0.0135). CONCLUSIONS: In external validation analysis, the more established Michigan RVF score-which emphasizes preoperative hemodynamic instability and target end-organ dysfunction-performed best, albeit modestly, in predicting RVF and demonstrated association with in-hospital and long-term mortality.

Increased Pulmonary-Systemic Pulse Pressure Ratio Is Associated With Increased Mortality in Group 1 Pulmonary Hypertension.

BACKGROUND: Pulmonary arterial hypertension (PAH) is characterised by remodelling of the pulmonary vasculature leading to right ventricular (RV) failure. The failing RV, through interventricular uncoupling, deleteriously impacts the left ventricle and overall cardiac efficiency. We hypothesised that the ratio of the pulmonary artery pulse pressure to the systemic pulse pressure ("pulmonary-systemic pulse pressure ratio", or PS-PPR) would be associated with mortality in PAH. METHODS: We conducted a retrospective analysis of 262 patients in the National Institute of Health Primary Pulmonary Hypertension Registry (NIH-PPH). We evaluated the association between the PS-PPR and mortality after adjustment for the Pulmonary Hypertension Connection (PHC) risk equation. RESULTS: Among 262 patients (mean age 37.5±15.8years, 62.2% female), median PS-PPR was 1.04 (IQR 0.79-1.30). In the Cox proportional hazards regression model, each one unit increase in the PS-PPR was associated with more than a two-fold increase in mortality during follow-up (HR 2.06, 95% CI 1.40-3.02, p=0.0002), and this association of PS-PPR with mortality remained significant in the multivariable Cox model adjusted for the PHC risk equation, mean pulmonary artery pressure, and body mass index (BMI) (adjusted HR 1.81, 95% CI 1.13-2.88, p=0.01). Furthermore, PS-PPR in the upper quartile (>1.30) versus quartiles 1-3 was associated with a 68% increase in mortality after adjustment for these same covariates (adjusted HR 1.68, 95% CI 1.13-2.50, p=0.01). CONCLUSIONS: Pulmonary-systemic pulse pressure ratio, a marker of biventricular efficiency, is associated with survival in PAH even after adjustment for the PHC risk equation. Further studies are needed on the wider applications of PS-PPR in PAH patients.

Plasma Volume and Renal Function Predict Six-Month Survival after Hospitalization for Acute Decompensated Heart Failure.

BACKGROUND: Plasma volume (PV) is contracted in stable patients with heart failure (HF) due to decongestion strategies. On the other hand, increased PV can adversely affect the trajectory of HF. We therefore examined the effects of increased percentage change in PV (%ΔPV), blood urea nitrogen (BUN), and %ΔPV stratified by BUN and glomerular filtration rate (GFR) on survival after discharge in patients hospitalized for acute decompensated HF (ADHF). METHODS: We used the Strauss-Davis-Rosenbaum formula to calculate the %ΔPV between baseline and hospital discharge in a cohort from the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial (ESCAPE). Kaplan-Meier curves were constructed for survival over 6 months. Cox proportional hazards regression was used to obtain adjusted hazard ratios (HR) and 95% confidence intervals (95% CI) for the associations between survival after discharge and %ΔPV, BUN, and %ΔPV stratified by BUN and GFR. RESULTS: Of the 324 patients included in our study (age 56.1 ± 13.6 years, 26.5% female), those with increased or no %ΔPV at discharge were less likely to survive at 6 months compared with those having reduced %ΔPV (log rank, p = 0.0093). Increased %ΔPV (HR 1.08 per 10% increase; 95% CI: 1.02-1.14) and increased BUN at discharge (HR 1.02 per mg/dL; 95% CI: 1.01-1.03) were independently associated with worse survival. Decreasing %ΔPV had a greater association with improved survival in patients with discharge BUN <31 mg/dL (p = 0.02) and discharge GFR >40 mL/min/1.73 m2 (p = 0.047). CONCLUSIONS: Increased %ΔPV and BUN at discharge predicted worse 6-month survival in patients with ADHF. Decreased %ΔPV with low BUN or high GFR at discharge was associated with improved survival.

Left ventricular assist device implantation strategies and outcomes.

Over the past 15 years, the field of mechanical circulatory support has developed significantly. Currently, there are a multitude of options for both short and long term cardiac support. Choosing the appropriate device for each patient depends on the amount of support needed and the goals of care. This article focuses on long term, implantable devices for both bridge to transplantation and destination therapy indications. Implantation strategies, including the appropriate concomitant surgeries are discussed as well as expected long term outcomes. As device technology continues to improve, long term mechanical circulatory support may become a viable alternative to transplantation.

Complex biliary stones: treatment with removable self-expandable metal stents: a new approach (with videos).

BACKGROUND: Complex biliary stones often require temporary stent placement before a repeat attempt at extraction. To date, covered self-expandable metal stents (CSEMSs) have not been formally investigated for this indication. OBJECTIVE: To evaluate the efficacy and safety of CSEMSs in patients with retained complex biliary stones. DESIGN: Retrospective case series. SETTING: Large quaternary-care center. PATIENTS: Thirty-six patients (24 women) with complex biliary stones with incomplete stone clearance after endoscopic retrograde cholangiography (ERC) with biliary sphincterotomy. INTERVENTIONS: Patients with incomplete stone clearance after ERC with biliary sphincterotomy underwent temporary placement of CSEMSs, with subsequent removal before repeat stone extraction. MAIN OUTCOME MEASUREMENTS: Success achieving immediate biliary drainage and eventual complete duct clearance. Procedure-related complications were also assessed. RESULTS: CSEMS placement was successful in establishing immediate biliary drainage in all 36 patients. Complete duct clearance at repeat ERC was achieved in 29 of 35 patients after a mean duration of 6.4 weeks. Four of the remaining 6 patients underwent sequential CSEMS placement, with eventual duct clearance after multiple ERCPs. There were no complications related to biliary obstruction. One patient died of a nonbiliary cause. Of the total 42 CSEMSs placed, there were 4 cases (9.5%) of clinically insignificant stent migration. LIMITATIONS: Single-center experience, retrospective design. CONCLUSIONS: CSEMSs permit management of complex biliary stones, but require multiple sessions. The cost-effectiveness of this technique needs further investigation.