Management of Pulmonary Mucormycosis After Orthotopic Heart Transplant: A Case Series.

Invasive pulmonary mucormycosis is a potentially fatal infection that can occur in immunosuppressed patients such as those who have undergone orthotopic heart transplant (OHT). High-dose intravenous antifungal agents, including amphotericin B, are generally accepted as the first-line medical treatment, with prompt surgical resection of lesions if feasible. The body of evidence guiding treatment decisions, however, is sparse, particularly regarding adjustment of immunosuppression during acute infection and long-term recovery. We present 2 cases of patients with pulmonary mucormycosis occurring within the first 6 months after OHT, both of whom successfully recovered after appropriate medical and surgical treatment, and we highlight differences in immunosuppression management strategies for this life-threatening condition.

Outcomes of pre- heart transplantation desensitization in a series of highly sensitized patients bridged with left ventricular assist devices.

Desensitization therapy for heart transplantation (HT) candidates can shorten transplant wait times and broaden the donor pool. Specific evidence-based recommendations on both protocols and indications are lacking. We retrospectively assessed left ventricular assist devices-bridged candidates who received pre-HT desensitization therapy. The therapeutic protocol consisted of intravenous immunoglobulin and rituximab followed by bortezomib and plasmapheresis if an insufficient response was achieved. Desensitization was attempted in 10 patients; only 7 tolerated therapy and underwent transplant. For those patients, median decrease in unacceptable calculated panel reactive antibody was 11%; there was no significant decrease for 3 patients. Post-desensitization adverse events were observed in all patients which included coagulopathy, bone marrow suppression, and infection. Median time to first infection was 16 days. One patient had clinically significant rejection and 3 patients had uptrending donor-specific antibodies. Decisions to proceed with desensitization should be individualized understanding potential risks and benefits.

A case series of patients with left ventricular assist devices and concomitant mechanical heart valves.

Mechanical heart valves left in situ at the time of left ventricular assist device (LVAD) implantation are thought to potentially increase the risk of thromboembolism. Recommendations exist to replace dysfunctional mechanical mitral valves and any mechanical aortic valves at the time of LVAD implantation. Due to potential increases in cardiopulmonary bypass time and associated comorbidities with valve replacement, leaving a functional mechanical valve in place at LVAD implantation has been suggested to be a safe option. We retrospectively reviewed all patients with prior mechanical mitral or aortic valves undergoing LVAD implantation at our center between 2012 and 2017. Echocardiograms were read by a single cardiologist to assess for mechanical valve dysfunction. We identified 15 patients. Five patients had major bleeding requiring transfusion. On follow-up, 2 patients had hemorrhagic stroke and 2 had transient ischemic attach/ischemic stroke. In addition, 2 patients had LVAD thrombosis and 2 patients had LVAD driveline malfunction. Mild mechanical valve regurgitation was identified on follow-up echocardiograms of 2 patients. Rate of complications in patients with mechanical valves undergoing LVAD implantation was comparable to that reported for the general LVAD population. Leaving a functional mechanical valve in place at the time of LVAD implantation could be a reasonable alternative to valve replacement. More data are required to further guide patient care in these individuals.

Venoarterial extracorporeal membrane oxygenation use in staged combined heart-kidney transplant.

Outside of heart and lung transplantation, only few cases have been reported describing venoarterial extracorporeal membrane oxygenation (VA-ECMO) use in solid organ transplantation. We present a case of a staged combined heart-kidney transplant in which VA-ECMO was utilized after a complicated orthotopic heart transplantation to successfully complete the subsequent renal transplantation.

Regional Variation in the Association of Poverty and Heart Failure Mortality in the 3135 Counties of the United States.

Background There is significant geographical variation in heart failure (HF) mortality across the United States. County socioeconomic factors that influence these outcomes are unknown. We studied the association between county socioeconomic factors and HF mortality and compared it with coronary heart disease (CHD) mortality. Methods and Results This is a cross-sectional analysis of socioeconomic factors and mortality in HF and CHD across 3135 US counties from 2010 to 2015. County-level poverty, education, income, unemployment, health insurance status, and cause-specific mortality rates were collected from the Centers for Disease Control and Prevention and US Census Bureau databases. Poverty had the strongest correlation with both HF and CHD mortality, disproportionately higher for HF (r=0.48) than CHD (r=0.24). HF mortality increased by 5.2 deaths/100 000 for each percentage increase in county poverty prevalence in a frequency-weighted, demographic-adjusted, multivariate regression model. The greatest attenuation in the poverty regression coefficient (66.4%) was seen after adjustment for prevalence of diabetes mellitus and obesity. Subgroup analysis by census region showed that this relationship was the strongest in the South and weakest in the Northeast (6.1 versus 1.4 deaths/100 000 per 1% increase in county poverty in a demographics-adjusted model). Conclusions County poverty is the strongest socioeconomic factor associated with HF and CHD mortality, an association that is stronger with HF than with CHD and varied by census region. Over half of the association was explained by differences in the prevalence of diabetes mellitus and obesity across the counties. Health policies targeting improvement in these risk factors may address and possibly minimize health disparities caused by socioeconomic factors.

Clinical Benefit of American College of Chest Physicians versus European Society of Cardiology Guidelines for Stroke Prophylaxis in Atrial Fibrillation.

BACKGROUND: Guidelines for anticoagulant therapy in patients with atrial fibrillation (AF) conflict with each other. The American College of Chest Physicians (ACCP) guidelines suggest no anticoagulant therapy for patients with a CHADS2 score of 0. The European Society of Cardiology (ESC) prefer anticoagulant therapy for patients with a CHA2DS2-VASc of 1, which includes 65-74-year-olds with a CHADS2 score of 0. Resolving this conflicting advice is important, because these guidelines have potential to change anticoagulant therapy in 10 % of the AF population. METHODS: Using the National Registry of Atrial Fibrillation (NRAF) II data set, we compared these guidelines using stroke equivalents. Based on structured review of 23,657 patient records, we identified 65-74-year-old patients with a CHADS2 stroke score of 0 and no contraindication to warfarin. We used Medicare claims data to ascertain rates of ischemic stroke, intracranial hemorrhage, and other hemorrhage. We calculated net stroke equivalents for these (N = 478) patients using a weight of 1.5 for intracranial hemorrhages (ICH) and 1.0 for ischemic stroke. In a multivariate analysis, we used 14,466 records with documented atrial fibrillation and adjusted for CHADS2 and HEMORR2 HAGES score. RESULTS: In 65-74-year-old patients with a CHADS2 stroke score of 0, the stroke equivalents per 100 patient-years was 2.6 with warfarin and 2.9 without warfarin; the difference between these two strategies was not significant (0.3 stroke equivalents, 95 % CI -3.2 to 3.7). However, rates of hemorrhage per 100 patient-years were nearly tripled (hazard ratio 2.9; 95 % CI 1.5-5.4; p = 0.0011) with warfarin (21.1) versus without it (7.4). The most common site for major hemorrhage was gastrointestinal (ICD-9 code 578.9). CONCLUSIONS: By expanding warfarin use to 65--74-year-olds with a CHADS2 score of 0, rates of hemorrhages would rise without a significant reduction in stroke equivalents.