Left atrial appendage occlusion using a Watchman device in a transplanted heart with biatrial anastomosis.

A percutaneous left atrial appendage (LAA) occlusion using a Watchman device was performed in a patient with prior biatrial anastomosis orthotopic heart transplant (OHT). Due to the anatomical changes following biatrial anastomosis, transesophageal echocardiography (TEE) imaging and transseptal puncture become technically challenging. We describe how the standard LAA views on TEE were obtained for device sizing, and how the transseptal puncture was modified to cross the scarred septum. This case demonstrates that LAA occlusion using a Watchman device in biatrial anastomosis OHT is safe and can successfully be done.

Mean Arterial Pressure to Central Venous Pressure Ratio: A Novel Marker for Right Ventricular Failure After Left Ventricular Assist Device Placement.

BACKGROUND: Early right ventricular failure (RVF) is common after left ventricular assist device (LVAD) implantation and often leads to increased morbidity and mortality. It is difficult to predict early RVF on the basis of clinical and hemodynamic parameters. We investigated the utility of mean arterial pressure (MAP) to central venous pressure (CVP) ratio in predicting early RVF. METHODS AND RESULTS: We analyzed a retrospective cohort of 212 consecutive patients who underwent hemodynamic assessment before destination-therapy LVAD implantation. Patients were followed for early RVF and mortality. Receiver operating characteristic (ROC) analysis was used to determine discriminative capacity of MAP/CVP and tested the diagnostic and prognostic value of median MAP/CVP threshold. The ROC analysis demonstrated that pre-LVAD MAP/CVP was associated with an area under the ROC curve of 0.65 (95% confidence interval 0.58-0.73; P < .001). MAP/CVP threshold <7.5 (simple nearest-to-median value) was associated with 70% sensitivity and 56% specificity for early RV failure. Patients with MAP/CVP <7.5 had a higher incidence of post-LVAD RVF than those with a ratio ≥7.5 (44% vs 23%, respectively; P = .001). Right ventricular assist device requirement was higher in the MAP/CVP <7.5 group (11% vs 2%; P = .01). All-cause mortality was higher in the MAP/CVP <7.5 group (annualized mortality 26% vs 16%; log-rank P = .017). MAP-CVP ratio provided incremental prognostic value for RVF and all-cause mortality beyond established Heartmate II and RVF risk scores. CONCLUSIONS: Our findings suggest that pre-LVAD MAP/CVP <7.5 is associated with early RVF and increased mortality risk. This novel parameter can be used in risk stratification of LVAD candidates. Prospective validation of our findings is needed.

The Influence of Pre-Left Ventricular Assist Device (LVAD) Implantation Glomerular Filtration Rate on Long-Term LVAD Outcomes.

BACKGROUND: Chronic kidney disease (CKD) is a known predictor for adverse outcomes in patients with advanced heart failure requiring left ventricular assist devices (LVADs). The effect of pre-LVAD glomerular filtration rate (GFR) on post-LVAD outcomes in CKD patients is not completely understood. Additionally, a subset of patients improve their GFR after LVAD placement. In this study we sought to determine the effects of pre-LVAD GFR on post-LVAD outcomes. METHODS: Two hundred and seventy consecutive patients with LVADs were enrolled. Patients were stratified based on a GFR cut-off of 60mL/min/1.73m2. Patients with preoperative GFR <60 were further divided into two subgroups based post-LVAD discharge GFR of 60. Post-LVAD major adverse effects were analysed. RESULTS: Patients with pre-implant GFR <60 had higher all cause mortality than patients with pre-implant GFR ≥60 (45% vs. 27%, p=0.006). These patients also had higher incidence of early right ventricular failure and congestive heart failure hospitalisations. Kaplan-Meier survival analysis confirmed poor survival in this group. When the subgroup analysis of patients in the GFR <60 cohort was performed, the above findings were heavily weighted towards patients who did not improve their GFR to ≥60 post-LVAD. CONCLUSION: Pre-implant GFR is an important prognostic marker in LVAD patients. Patients with pre-implant GFR <60 are at higher risk of cardiovascular morbidity and mortality. Our findings suggest that the patients who do not improve their GFR post-LVAD are at the highest risk.

Obesity as a Risk Factor for Consideration for Left Ventricular Assist Devices.

BACKGROUND: Obesity is a major risk factor for cardiovascular outcomes and is prevalent in patients with advanced heart failure requiring left ventricular assist devices (LVADs). The understanding of high body mass index (BMI) and outcomes after LVAD implantation continues to evolve. In this study we investigated the effects of obesity on post-LVAD implantation outcomes. METHODS AND RESULTS: In this retrospective study, 288 patients with both Heartmate II and Heartware HVADs, implanted as bridge to transplantation (BTT) and destination therapy (DT), were enrolled. Patients were stratified according to BMI ≥30 kg/m(2). Baseline demographics were obtained. Post-LVAD implantation incidence of readmissions and major adverse events were tabulated. The cohort comprised of 95 (33%) obese and 193 (67%) nonobese patients, as well as, 63 (25%) female and 225 (75%) male patients; 48 (20%) were implanted as BTT and 240 (80%) as DT. The mean BMI in the obese group was 35.2 kg/m(2) compared with 24.3 kg/m(2) (P < .001) in the control group. There was no difference in survival between the two groups. Incidence of post-LVAD implantation heart failure readmissions was higher in the obese cohort. (29% vs 16% P = .009). Multivariate analysis confirmed that BMI was an independent predictor for post-LVAD heart failure readmissions (odds ratio 2.47, 95% confidence interval 1.15-5.32; P = .02) Obese patients had a higher mean total number of hospitalizations compared with nonobese patients, (4.2 vs 3.4; P = .03) as well as higher median total length of stay after LVAD implantation (28 vs 14 days; P = .05), but these were not significant when adjusted for covariates. CONCLUSIONS: Obese patients had higher incidence of post-LVAD implantation heart failure readmissions. There was no difference in overall survival or outcomes between the 2 groups. There was no difference in total rehospitalizations or length of stay between obese and nonobese patients. Our analysis suggests that obesity should not preclude LVAD candidacy.

Clinical outcomes in sensitized heart transplant patients bridged with ventricular assist devices.

BACKGROUND: Left ventricular assist devices (LVADs) as a bridge to transplant (BTT) have been known to cause allosensitization, as measured by panel-reactive antibody (PRA) levels. The goal of this study was to measure the impact of this allosensitization on outcomes. METHODS: Panel-reactive antibodies were analyzed in BTT patients, with sensitization defined as peak PRAs ≥ 10%. Baseline characteristics and outcomes in the two patient groups were evaluated using descriptive statistics, Kaplan-Meier, and regression analysis. RESULTS: Thirty-eight patients were included in the study (17 sensitized vs. 21 non-sensitized). There were more women in the sensitized group (47% vs. 10%, p = 0.023). There was no difference in mean times to high-grade acute cellular rejection (ACR; 18.3 months in sensitized vs. 36.9 months in non-sensitized). Five patients in the sensitized groups developed antibody-mediated rejection (AMR) vs. 0 in the non-sensitized, and all five patients died (Kaplan-Meier log-rank p = 0.024). There was also a significant difference in the incidence of infection at the one- to six-month stage (52.9% vs. 19.0%, p = 0.03). CONCLUSION: Sensitization appears to have a negative effect on mortality. This mortality appears to be concentrated in patients with AMR, and we postulate that the development of AMR in a sensitized patient may be a predictor of mortality.

Changes in Spirometry After Left Ventricular Assist Device Implantation.

Left ventricular assist devices (LVADs) are increasingly being used as life-saving therapy in patients with end-stage heart failure. The changes in spirometry following LVAD implantation and subsequent unloading of the left ventricle and pulmonary circulation are unknown. In this study, we explored long-term changes in spirometry after LVAD placement. In this retrospective study, we compared baseline preoperative pulmonary function test (PFT) results to post-LVAD spirometric measurements. Our results indicated that pulmonary function tests were significantly reduced after LVAD placement (forced expiratory volume in one second [FEV1 ]: 1.9 vs.1.7, P = 0.016; forced vital capacity [FVC]: 2.61 vs. 2.38, P = 0.03; diffusing capacity of the lungs for carbon monoxide [DLCO]: 14.75 vs. 11.01, P = 0.01). Subgroup analysis revealed greater impairment in lung function in patients receiving HeartMate II (Thoratec, Pleasanton, CA, USA) LVADs compared with those receiving HeartWare (HeartWare, Framingham, MA, USA) devices. These unexpected findings may result from restriction of left anterior hemi-diaphragm; however, further prospective studies to validate our findings are warranted.

Neurogenic stress cardiomyopathy in heart donors.

Cardiac transplantation is severely restricted by donor availability. Left ventricular dysfunction due to neurogenic stress cardiomyopathy is often seen during donor evaluation and often presents a clinical dilemma for procurement. We report a case of a 23-year-old man with severe left ventricular dysfunction whose heart was successfully procured for transplantation. The brief case report is followed by an extensive review of neurogenic stress cardiomyopathy as well as donor evaluation for cardiac transplantation in the setting of such cardiomyopathy.

Intensity-Dependent Benefit of Statins in Survival Among Prospective Kidney Transplant Patients.

Statin use in patients listed for in kidney transplant is believed to be beneficial. However, the optimum statin dose for improved survival in this high-risk population is unknown. Our study aimed to determine the impact of prekidney transplant statin dosage on survival postkidney transplant. In this retrospective cohort study, we enrolled patients who underwent kidney transplant from January 2005 to September 2015 at Rush University Medical. Data on the statin use and intensity used before kidney transplant were obtained. The patient population was stratified into 2 groups based on prekidney transplant use of statins. Patients using any form of statin, without regard to the type and dose, were placed in the statin groups, whereas the rest were categorized as the no statin group. The statin group was further classified into low-intensity, moderate-intensity, and high-intensity statin subgroups based on the present atherosclerotic cardiovascular disease definition of statin intensity. The primary outcome was patient survival after kidney transplant. A total of 687 patients had data on statin use before kidney transplant were followed. Median follow-up time was 3.4 years (interquartile range 1.2 to 5.6 years). Multivariate analysis showed that the use of statins prekidney transplant was associated with improved survival postkidney transplant compared with prestatin group (Hazard ratio 0.56, confidence intervals 0.32 to 1.00, p = 0.05). When patients on statins were stratified by statin intensity, Kaplan-Meier survival analysis revealed a significant dose-dependent improvement in survival. Multivariate analysis showed that the relation between statin intensity and survival was maintained even after adjusting for confounder (hazard ratio 0.30, confidence intervals 0.18 to 0.51, p <0.001). In conclusion, our data indicate statistically significant survival benefit in patients receiving high-intensity statin before kidney transplant.

Is Diabetes Mellitus a Risk Factor for Poor Outcomes after Left Ventricular Assist Device Placement?

Diabetes mellitus is associated with adverse outcomes in patients with cardiovascular diseases, including heart failure. Left ventricular assist devices (LVADs) are increasingly used as life-saving therapy for advanced heart failure. The effects of pre-LVAD diabetes on long-term outcomes after LVAD implantation are not well understood. In this study, we retrospectively evaluated the effect of existing diabetes on post-LVAD outcomes. Data on 288 LVAD recipients from 2006 through 2013 were reviewed. Patients were stratified in accordance with their histories of diabetes. Baseline demographic, laboratory, hemodynamic, and echocardiographic information before LVAD placement were reviewed, together with the post-LVAD incidence of major adverse outcomes. Kaplan-Meier analysis and Cox regression analysis were performed. Our cohort comprised 122 patients with diabetes and 166 patients without. The mean glycosylated hemoglobin A1c level in the diabetes group was 7.4% ± 1.6%. Diabetic patients at baseline had a more adverse medical profile than did nondiabetic patients. There were no differences in major outcomes between the 2 groups other than a higher incidence of hemolysis in the diabetes group: 12 (10%) vs 5 (3%); P=0.02. There was no difference in survival outcomes between the groups. Diabetic patients did not have worse survival or more adverse outcomes than did nondiabetic patients in this study, perhaps because of improved diabetes control, or improvement in biochemical derangements after normalization of cardiac output with LVAD therapy. A diagnosis of diabetes was an independent predictor of hemolysis. Further studies to evaluate the link between hemolysis and diabetes are indicated.

Pre-transplant depression as a predictor of adherence and morbidities after orthotopic heart transplantation.

BACKGROUND: Psychosocial factors are useful predictors of adverse outcomes after solid organ transplantation. Although depression is a known predictor of poor outcomes in patients who undergo orthotopic heart transplantation (OHT) and is actively screened for during pre-transplant evaluation, the effects of early identification of this entity on post-transplant outcomes are not clearly understood. The purpose of this study was to evaluate the impact of pre-transplant depression on outcomes after OHT. METHOD: In this retrospective study, 51 patients that underwent psychosocial evaluation performed by a social worker prior to the transplant and followed up in our center post-transplant were enrolled. Patients were stratified by the presence/absence of depression during the initial encounter. Primary end-points were overall survival, 1st-year hospitalizations, overall hospitalizations, rejections, and compliance with medications and outpatient appointments. RESULTS: Depressed patients were 3.5 times more likely to be non-compliant with medications; RR = 3.5, 95% CI (1.2,10.2), p = 0.046 and had higher incidence of first year hospitalizations (4.7 ± 3.1 vs. 2.2 ± 1.9, p = 0.046), shorter time to first hospitalization 25 days (IQR 17-39) vs. 100 days (IQR 37-229), p = 0.001. Patients with depression also had higher overall hospitalizations (8.3 ± 4.4 vs. 4.6 ± 4.2, p = 0.025,) and higher number of admissions for infections (2.8 ± 1.3 vs. 1.5 ± 1.4, p = 0.018) compared to patients without depression. There were no statistically significant differences in total number of rejections or compliance with outpatient appointments. Kaplan-Meier survival analysis did not reveal differences between the two groups (mean 3705 vs. 3764 days, log-rank p = 0.52). CONCLUSION: Depression was a strong predictor of poor medication compliance and higher rates of hospitalization in transplant recipients. No difference in survival between depressed and non-depressed patients after OHT was noted.

Acute Heart Failure Exacerbation with Cardiogenic Shock and Elevated Systemic Vascular Resistance Treated with a Combination of Nicardipine and Dobutamine Therapy.

Acute heart failure is a common reason for hospital admission and is usually caused by decreased cardiac output either as a result of an intrinsic cardiac issue or as a result of severe hypertension with elevated afterload. We present a patient with a history of HFrEF who presented with acute heart failure, found to have hypotension requiring Dobutamine support and an elevated systemic vascular resistance requiring Nicardipine drip, with subsequent recovery of cardiac function.

Acute Cellular Rejection and C4d Positivity in Heart Transplantation : A Manifestation of Asymptomatic Antibody-Mediated Rejection?

OBJECTIVES: The role of routine C4d staining in endomyocardial biopsy specimens is uncertain. The implications of a diagnosis of acute cellular rejection (ACR) with a positive C4d with or without any evidence of antibody-mediated rejection (AMR) are unclear. This study sought to evaluate a distinct phenotype of ACR+/C4d+ in AMR- patients. METHODS: Data on C4d, ACR, and AMR were collected. Donor-specific antibody (DSA), panel-reactive antibody (PRA), flow crossmatch, and data on ACR and AMR episodes were also reviewed. RESULTS: Thirty-five patients were followed. Group I with C4d+ biopsy specimens was compared with group II with C4d- biopsy specimens. ACR greater than 1R was higher in group I compared with group II (50% vs 7.4%; P = .01). Clinical suspicion of AMR, positive retrospective crossmatches, and detection of de novo DSA were also higher in group I. CONCLUSIONS: Our result indicate that C4d and ACR positivity in posttransplant patients may be a harbinger of a subclinical form of asymptomatic AMR.

Clinical Benefits of Stem Cells for Chronic Symptomatic Systolic Heart Failure: A Systematic Review of the Existing Data and Ongoing Trials.

The benefits of stem cell therapy for patients with chronic symptomatic systolic heart failure due to ischemic and nonischemic cardiomyopathy (ICM and NICM, respectively) are unclear. We performed a systematic review of major published and ongoing trials of stem cell therapy for systolic heart failure and compared measured clinical outcomes for both types of cardiomyopathy. The majority of the 29 published studies demonstrated clinical benefits of autologous bone marrow-derived mesenchymal stem cells (BM-MSCs). Left ventricular ejection fraction (LVEF) was improved in the majority of trials after therapy. Cell delivery combined with coronary artery bypass grafting was associated with the greatest improvement in LVEF. Left ventricular end-systolic volume (or diameter), New York Heart Association functional classification, quality of life, and exercise capacity were also improved in most studies after cell therapy. Most ICM trials demonstrated a significant improvement in perfusion defects, infarct size, and myocardial viability. Several larger clinical trials that are in progress employ alternative delivery modes, cell types, and longer follow-up periods. Stem cells are a promising therapeutic modality for patients with heart failure due to ICM or NICM. More data are required from larger blinded trials to determine which combination of cell type and delivery mode will yield the most benefit with avoidance of harm in these patient populations.

Mechanical circulatory support improves diabetic control in patients with advanced heart failure.

AIMS: Left ventricular assist devices (LVADs) are increasingly being used as life-saving therapy for end-stage advanced heart failure. Diabetes is prevalent in advanced heart failure patients. In this study, we sought to investigate the effects of mechanical circulatory support on diabetic parameters with LVAD implantation. METHODS AND RESULTS: In this retrospective study, data on 244 LVAD recipients between 2006 and 2013 were reviewed. Patients without history of diabetes, death within the first 3 months after LVAD implantation, heart transplantation after LVAD, or LVAD explantation were excluded from the study. Baseline demographic, laboratory, and echocardiographic information prior to LVAD placement and 6-month follow-up were obtained. Laboratory values indicative of diabetic control were found to improve significantly at 6 months post-LVAD implantation (glycated haemoglobin, 7.2 vs. 6.1%, P < 0.0001; serum fasting glucose, 141 vs. 122 mg/dL, P = 0.003; mean daily insulin dose, 30 vs. 24 IU/day, P = 0.02). Additionally, the use of oral hypoglycaemic medication was successfully discontinued in six patients at 6 months post-LVAD implantation. CONCLUSIONS: Long-term LVAD therapy is associated with improvement in diabetic control which is probabvly due to improvements in cardiac output and normalization of biochemical derangements resulting from diabetes.

Calcified amorphous tumor of the left ventricular outflow tract.

We report a very rare case of a calcified amorphous tumor presenting atypically as a mobile left ventricular outflow tract mass in a 69-year-old female who was admitted for shortness of breath.

Impact of smoking status on cardiovascular outcomes following percutaneous coronary intervention.

BACKGROUND: Many military veterans in the United States with coronary artery disease continue to smoke despite undergoing percutaneous coronary intervention (PCI). Previous studies have described improved cardiovascular outcomes in smokers, the so-called "smokers' paradox." In this study, we examined the effects of smoking on cardiovascular outcomes following PCI. HYPOTHESIS: Do patients who smoke have different post-PCI outcomes than nonsmokers? METHODS: All patients who underwent PCI at a single US Veterans Administration hospital from 2004 to 2009 were followed. Outcomes of interest included myocardial infarction, unplanned coronary intervention, unplanned cardiac hospitalization, death, and a composite of events for 6 months after PCI. Changes in traditional risk factors were also assessed. RESULTS: Unadjusted analysis revealed that in almost all categories, smokers had lower incidence of adverse events than nonsmokers. However, after adjusting for the older age of the nonsmokers, no favorable statistical trend toward smokers was seen. Significant improvement in blood pressure and lipid levels were seen in both groups. CONCLUSIONS: After adjusting for differences in age, there did not appear to be any protective effect of smoking on cardiovascular outcomes following PCI. Smokers achieved similar degrees of risk factor optimization during the follow-up period as their nonsmoker counterparts. Aggressive efforts to decrease the prevalence of smoking must be maintained.