The association between novel clinical factors and gastrointestinal bleeding among patients supported with continuous-flow left ventricular assist device therapy.

BACKGROUND: This study explores novel preimplantation risk factors associated with gastrointestinal bleeding (GIB) after continuous-flow left ventricular assist device (CF-LVAD) implantation. CF-LVAD therapy implantation for patients with advanced heart failure is associated with a 20% to 40% incidence of GIB. METHODS: This study includes patients receiving CF-LVAD at a quaternary medical center from 2006 to 2014 (n = 254). The primary endpoint was GIB within 12 months after implantation; the secondary outcome was 3-year all-cause mortality. The Student t test or the χ2 test compared continuous or categorical variables. Competing risks analysis calculated the cumulative incidence of GIB postimplantation. Cox proportional hazards model was used for univariate/multivariate models predicting GIB. RESULTS: Sixty-four patients had GIB, with incidence rates at 1, 3, and 12 months of 11.8%, 19.3%, and 25.2%, respectively. Endoscopy revealed no identified source of bleeding in 41%; 33% of lesions were localized in the upper gastrointestinal tract, with the bulk (39%) categorized as vascular. Patients with prior gastrointestinal abnormalities (n = 98) had a greater risk of GIB post-CF-LVAD (HR 1.85 [1.11-3.09]; P = 0.02) than those with normal gastrointestinal evaluation results (n = 45) and those without preimplantation gastrointestinal evaluation (n = 111). Baseline blood urea nitrogen, chronic obstructive pulmonary disease, and prior percutaneous coronary intervention were statistically associated with post-CF-LVAD GIB. The presence of GIB within 12 months of CF-LVAD implantation was associated with an increased risk of 3-year all-cause mortality (HR 2.57 [1.57-4.15]; P < 0.01). CONCLUSIONS: First-year GIB is associated with increased mortality post-CF-LVAD. We advocate a closer examination of several GIB risk factors when evaluating CF-LVAD candidates.

Massive Left Ventricular Hypertrophy With Acromegaly: Hypertrophic Obstructive Cardiomyopathy Phenocopy or Phenotype?

Acromegaly-a rare endocrine disorder-results when a growth hormone-secreting somatotroph pituitary adenoma leads to increased insulin-like growth factor 1 production. Acromegaly is known to cause left ventricular hypertrophy. We present a case of acromegaly with massive left ventricular hypertrophy that was determined to be coexistent with gene-positive hypertrophic obstructive cardiomyopathy. (Level of Difficulty: Intermediate.).

Expecting the unexpected: right atrial mass in a transplant patient.

We present a 71-year-old male, who had had a heart transplantation 24 years prior, who came to our clinic with a low-grade fever and a new II/VI holosystolic murmur. Echocardiography showed a large mass in the right atrium with attachment near the junction of the right atrium and superior vena cava. The patient was taken to the operating room for resection of the mass. Microscopic evaluation was consistent with thrombus. Differential diagnosis of cardiac masses after cardiac transplant includes tumour, thrombus, and vegetation. Final diagnosis can be challenging; multimodality imaging and biopsy or resection often are required for final diagnosis.

A miniature right heart support system improves cardiac output and stroke volume during beating heart posterior/lateral coronary artery bypass grafting.

BACKGROUND: Certain heart manipulations carried out to access anastomotic sites during beating heart coronary artery bypass (OPCAB) compromise hemodynamics, and these risks can affect end-organ perfusion and limit patient selection. Evidence suggests that right heart support (RHS) augments left ventricular preload and provides hemodynamic stability. This study evaluated hemodynamic measures in OPCAB with RHS with respect to individual target vessels and general target distribution groups. METHODS: Beating heart surgery was performed on 52 patients with left ventricular preload managed with RHS. The average patient age was 69.9 years, and the average ejection fraction was 42.9% +/- 10.9%. Measurements of cardiac output, stroke volume, mean arterial pressure (MAP), heart rate, and cardiac index (CI) were taken at baseline, during each anastomosis with the optimal heart position, and when the RHS was momentarily interrupted prior to heart release. Anastomoses were categorized individually and into posterior/lateral (n = 91) or anterior/right (n = 90) groups and divided into the following output groups based on CI with optimal heart positioning without RHS: group 1 (low output; CI < 1.8), group 2 (marginal output; 1.8 < or = CI < 2.2), group 3 (acceptable output; CI > or = 2.2), and group 4 (output unchanged or increased). RESULTS: One hundred eighty-one vessels were grafted with an average of 3.5 per patient. Significant reductions in CI, MAP, and stroke volume were observed for all target vessels when RHS was briefly off, especially for posterior and lateral target vessels (12%-26% decrease). In both posterior/lateral and anterior/right target vessel groups, RHS improved CI and MAP in > or = 90% of the anastomoses (groups 1-3). Without RHS, 60% of posterior/lateral and 54% of anterior/right target positions resulted in critically low or marginal output (groups 1 and 2). There was one bypass conversion and no surgical interruptions, intraoperative intra-aortic balloon pump placements, or deaths. CONCLUSION: Augmenting left ventricular preload with RHS improves hemodynamic measures during OPCAB for all target vessel positions and provides critical support in a large number of anastomoses.

Comparison of Novacor and HeartMate vented electric left ventricular assist devices in a single institution.

We compared the survival outcomes, left ventricular assist device (LVAD)-related hospitalization, stroke, infection, panel reactive antibody, and blood product use data among 13 Novacor and 51 HeartMate system recipients. Stroke was significantly higher in Novacor patients, as was blood product use at the time of heart transplantation, likely due to long-term anti-coagulation, while the LVAD-related hospitalization and infections did not differ between the 2 groups. A positive panel reactive antibody was seen more among the HeartMate patients, but did not have a significant clinical impact and may not represent a true allosensitization.