Induced Hypothermia in Patients with Cardiac Arrest and a Non-shockable Rhythm: Meta-analysis and Trial Sequential Analysis.

BACKGROUND: Controversy surrounds utilization of induced hypothermia (IHT) in comatose cardiac arrest (CA) survivors with a non-shockable rhythm. METHODS: We conducted a meta-analysis and trial sequential analysis (TSA) comparing IHT with no IHT approaches in patients with CA and a non-shockable rhythm. The primary outcome of interest was favorable neurological outcomes (FNO) defined using the Cerebral Performance Category (CPC) score of 1 or 2. Secondary endpoints were survival at discharge and survival beyond 90 days. RESULTS: A total of 9 studies with 10,386 patients were included. There was no difference between both groups in terms of FNO (13% vs. 13%, RR 1.34, 95% CI 0.96-1.89, p = 0.09, I2 = 88%), survival at discharge (20% vs. 22%, RR 1.09, 95% CI 0.88-1.36, p = 0.42, I2 = 76%), or survival beyond 90 days (16% vs. 15%, RR 0.92, 95% CI 0.61-1.40, p = 0.69, I2 = 83%). The TSA showed firm evidence supporting the lack of benefit of IHT in terms of survival at discharge. However, the Z-curves failed to cross the conventional and TSA (futility) boundaries for FNO and survival beyond 90 days, indicating lack of sufficient evidence to draw firm conclusions regarding these outcomes. CONCLUSION: In this meta-analysis of 9 studies, the utilization of IHT was not associated with a survival benefit at discharge. Although the meta-analysis showed lack of benefit of IHT in terms of FNO and survivals beyond 90 days, the corresponding TSA showed high probability of type-II statistical error, and therefore more randomized controlled trials powered for these outcomes are needed.

Cardiac mechanics in heart failure with preserved ejection fraction.

Heart failure with preserved ejection fraction (HFpEF) is a complex clinical entity associated with significant morbidity and mortality. Common comorbidities including hypertension, coronary artery disease, diabetes, chronic kidney disease, obesity, and increasing age predispose to preclinical diastolic dysfunction that often progresses to frank HFpEF. Clinical HFpEF is typically associated with some degree of diastolic dysfunction, but can occur in the absence of many conventional diastolic dysfunction indices. The exact biologic links between risk factors, structural changes, and clinical manifestations are not clearly apparent. Innovative approaches including deformation imaging have enabled deeper understanding of HFpEF cardiac mechanics beyond conventional metrics. Furthermore, predictive analytics through data-driven platforms have allowed for a deeper understanding of HFpEF phenotypes. This review focuses on the changes in cardiac mechanics that occur through preclinical myocardial dysfunction to clinically apparent HFpEF.

Heart Transplantation in Giant Cell Myocarditis: Analysis of the United Network for Organ Sharing Registry.

BACKGROUND: Giant cell myocarditis (GCM) is a lethal, rapidly progressive disease, for which heart transplantation is the treatment of choice. We sought to describe the characteristics and outcomes of patients with GCM who undergo heart transplantation. METHODS AND RESULTS: We used the United Network for Organ Sharing thoracic organ transplantation registry to identify adults with GCM as the primary diagnosis and compared their characteristics and outcomes with patients who underwent transplantation for other types of myocarditis and for idiopathic dilated cardiomyopathy (IDCMP). A total of 32 patients with GCM were compared with 219 patients with myocarditis and 14,221 patients with IDCMP. Median age at listing for GCM was 52 years (interquartile range 40-55 y), and the majority were white (94%), male (63%), and listed as 1A (44%). Biventricular assist devices were used more frequently in GCM compared with IDCMP (31% vs 2%; P < .001). After transplantation, there were no statistically significant differences among GCM, myocarditis, and IDCMP patients regarding pacemaker implantation, dialysis initiation, or stroke rate. GCM patients had increased risk of acute rejection compared with IDCMP patients (16% vs 5.0%; P = .021) but no difference in rehospitalization for rejection among the 3 etiologies (P = .88). The cumulative survivals for GCM patients at 1, 5, and 10 years were 94%, 82%, and 68%, respectively, which was similar to the other etiologies (P = .11). CONCLUSIONS: Compared with patients with IDCMP, those with GCM present more acutely and have significantly higher utilization of biventricular mechanical circulatory support. Despite higher rates of early rejection, post-transplantation survival of patients with GCM was similar to that of other myocarditides and IDCMP.

Advanced Heart Failure Therapies for Cancer Therapeutics-Related Cardiac Dysfunction.

End-stage heart failure in cancer survivors may result from cardiotoxic chemotherapy and/or chest radiation and require advanced therapies, including left ventricular assist devices (LVADs) and transplantation. Traditionally, such therapies have been underutilized in cancer survivors owing to lack of experience and perceived risk of cancer recurrence. Recent data from large registries, however, have shown excellent outcomes of LVADs and transplantation in cancer survivors, albeit subject to careful selection and special considerations. This article summarizes all aspects of advanced heart failure therapies in patients with cancer therapy-related cardiac dysfunction and underscores the need for careful selection of these candidates.

Sex-based outcomes of surgical myectomy for hypertrophic cardiomyopathy: An analysis from the National Readmission Database.

BACKGROUND: There is a paucity of data on sex differences in outcomes after surgical myectomy (SM) for hypertrophic cardiomyopathy (HCM). METHODS: Patients who received SM for HCM during October 1, 2015, through December 31, 2018, were identified from the US National Readmission Database. The primary end point of this study was in-hospital mortality. The secondary end points were major bleeding, acute kidney injury, new pacemaker implantation, severe disability surrogates (non-home discharge and need for mechanical ventilation), resources utilization surrogates (length of stay and cost of hospitalization), and 30-day outcomes (readmission rate, mortality, and new pacemaker insertion). RESULTS: A total of 3031 patients were included in the current analysis. Using propensity score matching, 2 well matched cohorts were compared (women = 1170 and men = 1127). Women had a higher requirement for new pacemaker insertion compared with men (10.9% vs 6.8%; P = .029), higher number of non-home discharges (13.8% vs 7.9%; P < .01), and longer length of hospital stay (median = 7 [interquartile range, 5-9] days) versus (median = 6 [interquartile range, 5-8] days). There was no difference in in-hospital mortality, major bleeding, blood transfusion, acute kidney injury, or hospitalization costs for women versus men. At 30 days, women continued to show a higher need for pacemaker insertion (11.3% vs 7.1%; P = .03) and had a higher readmission rate than men (10.9% vs 7.1%; P = .02). There was no difference in 30-day mortality between women and men (3% vs 2.4%; P = .54). CONCLUSIONS: Among the HCM cohort who received SM, significant sex-based differences in the outcomes were observed. Women had higher new pacemaker insertion rate, higher non-home discharge rate, and higher rate of 30-day readmission compared with men.

Apixaban and rivaroxaban use for atrial fibrillation in patients with obesity and BMI ≥50 kg/m2.

BACKGROUND: Apixaban and rivaroxaban are increasingly used for thromboembolism prophylaxis in patients with non-valvular atrial fibrillation (NVAF) and commonly in patients with obesity and body mass index (BMI) ≥50 kg/m2 despite the limited data. OBJECTIVES: This study aimed to establish the effectiveness and safety of apixaban and rivaroxaban in patients with NVAF and BMI ≥50 kg/m2 . METHODS: A single health-system, retrospective cohort study evaluated the effectiveness and safety of apixaban and rivaroxaban initiated in adult patients (≥18 years of age) with BMI ≥50 kg/m2 and NVAF. Outcomes of ischemic stroke, systemic embolic events, and bleeding were compared to a cohort of patients with BMI 18 to 30 kg/m2 . RESULTS: After 1619 patient-years worth of follow-up in 595 patients, the primary endpoint of incidence of ischemic stroke was numerically similar in both groups, 1.3 per 100 patient-years in the BMI ≥50 kg/m2  group, compared to 2.0 per 100 patient-years in the BMI <30 kg/m2  group (RR 0.65, 95% CI 0.38-1.82, p = 0.544). Incidence of major bleeding and clinically relevant non-major bleeding was also numerically similar between the two groups. CONCLUSIONS: This study demonstrated that apixaban and rivaroxaban in patients with a BMI ≥50 kg/m2 for treatment of NVAF may be safe and effective at preventing thromboembolic events and had no increased risk of bleeding. Although, findings should be interpreted with caution and confirmed with additional studies. This study contributes to the growing body of evidence that direct oral anticoagulants (DOACs) may be effective and safe to use for the treatment of NVAF in patients with BMI ≥50 kg/m2 .

Cardiovascular outcomes and trends of Transcatheter vs. Surgical aortic valve replacement among octogenarians with heart failure: A Propensity Matched national cohort analysis.

Background: Heart failure (HF) is a complex clinical syndrome with symptoms and signs that result from any structural or functional impairment of ventricular filling or ejection of blood. Limited data is available regarding the in-hospital outcomes of TAVR compared to SAVR in the octogenarian population with HF. Methods: The National Inpatient Sample (NIS) database was used to compare TAVR versus SAVR among octogenarians with HF. The primary outcome was in-hospital mortality. The secondary outcome included acute kidney injury (AKI), cerebrovascular accident (CVA), post-procedural stroke, major bleeding, blood transfusions, sudden cardiac arrest (SCA), cardiogenic shock (CS), and mechanical circulatory support (MCS). Results: A total of 74,995 octogenarian patients with HF (TAVR-HF n = 64,890 (86.5%); SAVR n = 10,105 (13.5%)) were included. The median age of patients in TAVR-HF and SAVR-HF was 86 (83-89) and 82 (81-84) respectively. TAVR-HF had lower percentage in-hospital mortality (1.8% vs. 6.9%;p < 0.001), CVA (2.5% vs. 3.6%; p = 0.009), SCA (9.9% vs. 20.2%; p < 0.001), AKI (17.4% vs. 40.8%); p < 0.001), major transfusion (26.4% vs 67.3%; p < 0.001), CS (1.8% vs 9.8%; p < 0.001), and MCS (0.8% vs 7.3%; p < 0.001) when compared to SAVR-HF. Additionally, post-procedural stroke and major bleeding showed no significant difference. The median unmatched total charges for TAVR-HF and SAVR-HF were 194,561$ and 246,100$ respectively. Conclusion: In this nationwide observational analysis, TAVR is associated with an improved safety profile for octogenarians with heart failure (both preserved and reduced ejection fraction) compared to SAVR.

Hereditary Apolipoprotein A-I-Associated Cardiac Amyloidosis: Importance of Endomyocardial Biopsy When Suspicion Remains High.

Cardiac amyloidosis has recently garnered substantial attention. Although the advent of noninvasive diagnostic algorithms revolutionized diagnosis, endomyocardial biopsy may still be considered in select cases to determine the amyloidosis subtype definitively. We report a case of a patients with a known mutation causing hereditary apolipoprotein A-I-associated cardiac amyloidosis. (Level of Difficulty: Advanced.).

Invasive Hemodynamic Monitoring in Cardiogenic Shock Is Associated With Lower In-Hospital Mortality.

Background There is increasing utilization of cardiogenic shock treatment algorithms. The cornerstone of these algorithms is the use of invasive hemodynamic monitoring (IHM). We sought to compare the in-hospital outcomes in patients who received IHM versus no IHM in a real-world contemporary database. Methods and Results Patients with cardiogenic shock admitted during October 1, 2015 to December 31, 2018, were identified from the National Inpatient Sample. Among this group, we compared the outcomes among patients who received IHM versus no IHM. The primary end point was in-hospital mortality. Secondary end points included vascular complications, major bleeding, need for renal replacement therapy, length of stay, cost of hospitalization, and rate of utilization of left ventricular assist devices and heart transplantation. Propensity score matching was used for covariate adjustment. A total of 394 635 (IHM=62 565; no IHM=332 070) patients were included. After propensity score matching, 2 well-matched groups were compared (IHM=62 220; no IHM=62 220). The IHM group had lower in-hospital mortality (24.1% versus 30.6%, P<0.01), higher percentages of left ventricular assist devices (4.4% versus 1.3%, P<0.01) and heart transplantation (1.3% versus 0.7%, P<0.01) utilization, longer length of hospitalization and higher costs. There was no difference between the 2 groups in terms of vascular complications, major bleeding, and the need for renal replacement therapy. Conclusions Among patients with cardiogenic shock, the use of IHM is associated with a reduction in in-hospital mortality and increased utilization of advanced heart failure therapies. Due to the observational nature of the current study, the results should be considered hypothesis-generating, and future prospective studies confirming these findings are needed.

Inadvertent Disabling of Implantable Cardiac Defibrillator Antitachycardia Therapies Following Breast Reconstructive Surgery.

A 47-year-old woman with an implantable cardiac defibrillator and breast cancer underwent left breast mastectomy with simultaneous reconstruction using a breast tissue expander. She was found to have intermittent disabling of tachyarrhythmia detection and therapy functions of her implantable cardiac defibrillator that were triggered by the breast tissue expander magnetic port.

Myocardial Mechanics in Patients With Normal LVEF and Diastolic Dysfunction.

Heart failure with preserved ejection fraction (HFpEF) is a complex clinical entity that is poorly understood yet present in up to 5.5% of the general population. Proven therapies for this disorder are lacking, even though it has a similar prognosis to that of heart failure with reduced ejection fraction (HFrEF). Innovative imaging techniques have provided in-depth understanding of the unique pattern of left ventricular mechanics in patients with HFpEF who progress through preclinical (Stages A to B) and clinical (Stages C to D) American College of Cardiology/American Heart Association heart failure stages. This review highlights the mechanical basis of this disorder from the cellular and myofiber level to chamber dysfunction. As each chamber of the heart is examined, specific biomarkers and echocardiographic parameters with diagnostic and prognostic values are discussed. Finally, novel phenotyping methods including machine learning are reviewed that integrate these mechanics into clinical groups to advise and treat patients.

Use of the Burden of Diabetes Mellitus Score for Cardiovascular Disease Risk Assessment.

Uncontrolled type II diabetes mellitus (DM) using single point hemoglobin A1c levels has been associated with poor cardiovascular outcomes. However, methods to quantify the effect of uncontrolled DM over time have been inconsistent. To quantify hyperglycemia over time and assess its cardiovascular effects we developed and tested a DM burden score which accounts for time in years prior to DM diagnosis, diagnostic HbA1c, and aggregate HbA1c levels thereafter. A retrospective cohort study was performed with patients (n = 188) from a single academic center with type II DM and no prior cardiac disease history. Patient scores were calculated from diagnosis until the year 2015 and were grouped into low (<5.3%; n = 55), moderate (5.3% to 5.5%; n = 80), and high (>5.5%; n = 53) DM burden score cohorts. At 48 months, the cohort with high DM burden scores correlated with significantly worse major adverse cardiovascular events (hazard ratio [HR] 3.07, p = 0.012), myocardial infarction (HR 12.78, p = 0.015), coronary revascularization (HR 4.53, p = 0.019), cardiovascular hospitalizations (HR 4.20, p = 0.005), and all-cause hospitalizations (HR 2.57, p = 0.01). Cardiovascular and all-cause mortality showed significant difference between groups in log-rank testing. Also, a multivariate regression model showed DM burden score (p = 0.045) to be an independent predictor of major adverse cardiovascular events (HR 9.38, p = 0.045). In conclusion, this study provides evidence that DM control over time impacts cardiovascular outcomes.