Preoperative Amiodarone and Primary Graft Dysfunction in Heart Transplantation.

BACKGROUND: Preoperative amiodarone effects on postorthotopic heart transplant (OHT) outcomes remain controversial. OBJECTIVE: The purpose of this study was to determine the effect of cumulative pre-OHT amiodarone exposure on severe primary graft dysfunction (PGD). METHODS: We retrospectively reviewed adult OHT recipients between August 2012 and June 2018. Primary outcome was severe PGD in patients receiving amiodarone at 3, 6, and 12 months prior to OHT compared with those not receiving amiodarone. Secondary outcomes included intensive care unit (ICU) and hospital length of stay, duration of mechanical ventilation, early graft failure (EGF), mortality at 3, 6, and 12 months post-OHT, and 30-day incidence of postoperative tachyarrhythmias, bradycardia, permanent pacemaker implantation, and rejection. RESULTS: Incidence of severe PGD was 12.5% in those who received amiodarone compared to 6.8% in those who did not (14 vs 6, P = 0.18). Cumulative preoperative amiodarone significantly increased the odds of severe PGD at 3 months (odds ratio [OR]: 1.03; 95% confidence interval [CI]: 1.001-1.06; P = 0.044) and 6 months (OR: 1.02, 95% CI: 1.003-1.044; P = 0.024) in a multivariate logistic regression. Patients on amiodarone had significantly higher rates of postoperative bradycardia (13.4% vs 4.5%, P = 0.03). CONCLUSION AND RELEVANCE: A trend toward increased PGD was present in patients receiving preoperative amiodarone. This finding combined with the regression showing significantly increased odds of PGD with increasing 3 and 6 month cumulative amiodarone dose is clinically concerning. Escalation of care with pacemaker implantation was required more frequently in patients on pre-OHT amiodarone.

Feasibility, Acceptability, and Intervention Description of a Mobile Health Intervention in Patients With Heart Failure.

Mobile health (mHealth) is used to encourage and support self-management skills in patients with heart failure. The purpose of the study was to describe the feasibility, fidelity, usability, and acceptability of mHealth interventions. This pilot study used a randomized 3-group (enhanced usual care, mHealth, and mHealth plus, which included a nurse practitioner and community health worker) repeated-measure design to determine the feasibility of using a self-management behavior app and a Bluetooth-enabled scale for daily self-monitoring of weights and medications. In the 2 mHealth groups, of the 48 patients, 38 (79%) engaged partially in recording daily weights and medications, and of the 74 patients in the sample, we obtained partial to complete data on 63 (85%) of the patients during follow-up outcome phone calls. Most patients found the intervention to be feasible, usable, and acceptable, and (93%) patients in the mHealth group and 100% of patients in the mHealth plus group agreed or strongly agreed that they learned how to self-manage their heart failure using the app. The intervention was reasonable to implement and provided insight for future intervention improvements.

The HEART Camp Exercise Intervention Improves Exercise Adherence, Physical Function, and Patient-Reported Outcomes in Adults With Preserved Ejection Fraction Heart Failure.

BACKGROUND: Despite exercise being one of few strategies to improve outcomes for individuals with heart failure with preserved ejection fraction (HFpEF), exercise clinical trials in HFpEF are plagued by poor interventional adherence. Over the last 2 decades, our research team has developed, tested, and refined Heart failure Exercise And Resistance Training (HEART) Camp, a multicomponent behavioral intervention to promote adherence to exercise in HF. We evaluated the effects of this intervention designed to promote adherence to exercise in HF focusing on subgroups of participants with HFpEF and heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS: This randomized controlled trial included 204 adults with stable, chronic HF. Of those enrolled, 59 had HFpEF and 145 had HFrEF. We tested adherence to exercise (defined as ≥120 minutes of moderate-intensity [40%-80% of heart rate reserve] exercise per week validated with a heart rate monitor) at 6, 12, and 18 months. We also tested intervention effects on symptoms (Patient-Reported Outcomes Measurement Information System-29 and dyspnea-fatigue index), HF-related health status (Kansas City Cardiomyopathy Questionnaire), and physical function (6-minute walk test). Participants with HFpEF (n = 59) were a mean of 64.6 ± 9.3 years old, 54% male, and 46% non-White with a mean ejection fraction of 55 ± 6%. Participants with HFpEF in the HEART Camp intervention group had significantly greater adherence compared with enhanced usual care at both 12 (43% vs 14%, phi = 0.32, medium effect) and 18 months (56% vs 0%, phi = 0.67, large effect). HEART Camp significantly improved walking distance on the 6-minute walk test (η2 = 0.13, large effect) and the Kansas City Cardiomyopathy Questionnaire overall (η2 = 0.09, medium effect), clinical summary (η2 = 0.16, large effect), and total symptom (η2 = 0.14, large effect) scores. In the HFrEF subgroup, only patient-reported anxiety improved significantly in the intervention group. CONCLUSIONS: A multicomponent, behavioral intervention is associated with improvements in long-term adherence to exercise, physical function, and patient-reported outcomes in adults with HFpEF and anxiety in HFrEF. Our results provide a strong rationale for a large HFpEF clinical trial to validate these findings and examine interventional mechanisms and delivery modes that may further promote adherence and improve clinical outcomes in this population. CLINICAL TRIAL REGISTRATION: URL: https://clinicaltrials.gov/. Unique identifier: NCT01658670.

Mobile Health Self-management Interventions for Patients With Heart Failure: A Pilot Study.

BACKGROUND: Heart failure (HF) is a multifaceted syndrome that requires self-management for adherence to treatment to control symptoms. Symptoms need to be monitored to prevent impending HF exacerbations. Few HF study authors have assessed efficacy of mobile health (mHealth) interventions particularly with virtual visits to evaluate outcomes such as symptoms and healthcare utilization. OBJECTIVE: The aim of this pilot study was to evaluate the potential effect of mHealth self-management interventions on symptom status and health-related quality of life and describe health care utilization in patients with HF. METHODS: This 3-month pilot study included 74 patients with HF and used a randomized 3-group repeated-measures design (enhanced usual care, mHealth, and mHealth plus [+] virtual visits). Surveys included the Heart Failure Symptom Survey, EuroQol, and a specialized phone application for patients to report weights and medications. RESULTS: The mHealth groups had an overall decrease in most symptom severity and frequency, particularly shortness of breath. Compared to enhanced usual care, both the mHealth+ and mHealth groups showed promise with medium effect sizes (range .55-.60) in relation to shortness of breath and a medium effect (.51) for lower extremity edema for the mHealth+ group. There was a trend toward improvement in health-related quality of life in both intervention groups at month 3. The mHealth+ group had fewer rehospitalizations. CONCLUSIONS: In general, both mHealth groups fared better on symptoms and health care utilization. Small to medium effect sizes on selected symptom outcomes warrant this study to be conducted in a fully powered study. Virtual visits may assist in symptom recognition and self-management.

Impact of temporary mechanical circulatory support for early graft failure on post-heart transplantation outcomes.

Although temporary mechanical circulatory support (tMCS) for hemodynamic failure following heart transplantation is associated with increased early morbidity and mortality, the impact of etiology of graft dysfunction and long-term clinical implications are less well known. The objective of our study was to evaluate outcomes in patients who required venoarterial extracorporeal membrane oxygenation (VA ECMO) or temporary right ventricular assist device (RVAD) support for either primary or secondary early graft dysfunction. Hospital mortality in 27 patients who required tMCS following heart transplantation at our institution between 2007 and 2017 was 56%, 30% in patients with right ventricular dysfunction secondary to increased afterload, 60% in patients with primary graft dysfunction, and 100% in patients with graft failure secondary to coagulopathy with intraoperative bleeding or overwhelming sepsis. Conditional 1-year and 5-year survival was comparable between patients with, and without, the need for post-transplantation support with tMCS (98% and 89%; 92% and 65% at 1 and 5 years, P = .21). Etiology of early graft failure plays an important part in determining the short-term post-heart transplantation outcome. Although complications associated with tMCS use, such as renal dysfunction and infection, extend beyond index transplant hospitalization, long-term conditional survival is not compromised.

"Working me to life" - Longitudinal Perceptions from Adults with Heart Failure with Preserved Ejection Fraction Enrolled in an Exercise Training Clinical Trial.

AIMS: Adults with heart failure with preserved ejection fraction (HFpEF) responded more favorably to an exercise intervention compared to those with reduced ejection fraction. This study explores factors that contributed to this response focusing on the qualitative perceptions of adults with HFpEF enrolled in an exercise intervention. METHODS AND RESULTS: This qualitative descriptive study is a secondary analysis of longitudinal interviews collected at 3, 6, 12, and 18-months from participants with HFpEF enrolled in a randomized controlled trial testing an intervention to promote adherence to exercise. We included participants with at least 2 interviews. Interviews were examined across and within participants and time points using thematic analysis. Analyses included 67 interviews from 21 adults with HFpEF enrolled in the intervention arm. The sample was 52% (11/21) male and over 47% (10/21) non-White. Mean age at enrollment was 63.7 ± 9.9 years. We identified 4 major themes: 1. Overcoming negative attitudes, barriers, and injury, 2. Motivations to exercise, 3. Exercise - the panacea for HFpEF symptoms and quality of life, and 4. Advice for others with HFpEF. CONCLUSIONS: Our findings suggest that for many adults with HFpEF, initial hesitancy, fear, and negative attitudes about exercise can be overcome. Exercise coaching using social cognitive constructs, medical fitness center memberships, and heart rate self-monitoring are successful strategies of engaging adults with HFpEF in long-term unsupervised exercise training. REGISTRATION: This study is registered at ClinicalTrials.gov, NCT01658670.

Hemodynamic Monitoring Devices in the Management of Outpatient Heart Failure.

The prevalence of heart failure continues to increase throughout the world. This rise in diagnoses corresponds with high rates of hospitalization, patient and caregiver fatigue, and ever-increasing economic costs. While numerous investigations have been undertaken in the past looking into remote monitoring or telemedicine strategies, they were unable to show an improvement in clinical outcomes with use. Invasive hemodynamic monitoring in the ambulatory setting has been an area of focus for the last several decades as a possible proactive strategy aiding in the evaluation and management of the heart failure population. Several large, randomized trials have not only shown the safety of a pulmonary artery pressure sensor in the heart failure population but have also confirmed the efficacy of pulmonary artery pressure-guided heart failure management in reducing rates of heart failure hospitalizations. Additional novel implantable devices are in various stages of development and clinical investigation and aim to further help aid in the management of this complex patient population. Future strategies are emerging and include the increased development of wearable devices as well as novel technologies to assess hemodynamics and volume status.

The role of a multidisciplinary heart failure clinic in optimization of guideline-directed medical therapy: HF-optimize.

BACKGROUND: Guideline-directed medical therapy (GDMT) reduces mortality and hospitalizations in adults with heart failure with reduced ejection fraction (HFrEF); however, few are receiving GDMT. National registries show as few as 1% of patients are receiving appropriate GDMT. Development of heart failure clinics achieving optimal GDMT are crucial to improve outcomes for HFrEF patients. OBJECTIVE: We developed a multidisciplinary HF-Optimize clinic aimed at improving GDMT use along with providing education, resources, and comorbidity screening for adults with HFrEF. METHODS: We targeted patients with newly diagnosed HFrEF and/or recent or multiple admissions for 6 visits over 12 weeks. We measured medication use, ejection fraction, 6-minute walk test distance, and health-related quality of life (EuroQol Visual Analog Scale) at visits 1 and 6. RESULTS: One-hundred ten patients completed all visits. Patients were a mean age of 58 (±14) years, 37% were female, and 42% were of non-White race. From visit 1 to visit 6, utilization of GDMT increased from 35.5% to 85.5% (p < 0.001) and significant improvements in ejection fraction (25.9% to 35.5%, p < 0.001), 6-minute walk distance (1032 feet to 1121.7 feet, p = 0.001), and quality of life (63.8/100 vs 70.8/100, p = 0.002). Only 2 patients (1.8%) that completed HF-Optimize had a 30-day heart failure readmission. CONCLUSION: Our multidisciplinary HF-Optimize clinic improved medication usage and clinical outcomes. Further studies are needed to validate outcomes of multidisciplinary GDMT clinics.

Is Methamphetamine-Linked Cardiomyopathy an Emerging Epidemic for New Generation?

The use of methamphetamines is growing worldwide with cardiovascular disease as the leading cause of mortality and morbidity. Long-term use of methamphetamines is associated with malignant hypertension, myocardial ischemia, pulmonary hypertension, and methamphetamines-associated cardiomyopathy. These effects are noted to be dose-dependent and potentially reversible with discontinuation of methamphetamines in the early stages when there is limited or no myocardial fibrosis. This review aims to (1) summarize the available data from epidemiologic studies, (2) describe pathophysiological mechanisms and clinical presentation, (3) Management of methamphetamines induced cardiomyopathy and potential complications associated with it, and (4) Strategies to reduce methamphetamines abuse and related hospitalization.

Sodium-Glucose Cotransporter-2 Inhibitors in Heart Failure With Mildly Reduced or Preserved Ejection Fraction: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduce the risk of heart failure (HF) hospitalizations and cardiovascular mortality among patients with HF and left ventricular ejection fraction (LVEF) ≤40%. There is emerging evidence of the benefits of SGLT2i in HF patients with a higher LVEF (>40%). We aimed to evaluate the benefits of SGLT2i in different subgroups of patients with HF and LVEF >40%. METHODS: We searched PubMed, EMBASE, clinicaltrials.gov, Cochrane, and Google Scholar for randomized controlled trials (RCTs) comparing outcomes of SGLT2i vs placebo in patients with HF and LVEF >40%. The hazard ratios (HRs) and 95% confidence intervals (CIs) in each study were used for the meta-analysis. The primary composite outcome (PCO) was HF hospitalization or cardiovascular mortality. Secondary outcomes included HF hospitalization, cardiovascular mortality, and all-cause mortality. RESULTS: Six RCTs with 15,989 patients were included (median follow-up = 27.3 months, 40.8% females). In patients with HF and LVEF >40%, SGLT2i were associated with significantly lower PCO compared to placebo (HR 0.80; 95% CI 0.74-0.86; P < 0.001). This was consistent across 10 of 13 subgroups examined, including LVEF. SGLT2i also reduced HF hospitalization but not cardiovascular or all-cause mortality. Patients <65 years old, from racial minorities, or from Asia receiving SGLT2i did not demonstrate a significant reduction in PCO. CONCLUSIONS: SGLT2i significantly reduce the combined risk of HF hospitalization or cardiovascular mortality among patients with HF and LVEF >40%. However, younger patients, racial minorities, and patients from Asia did not demonstrate such a reduction. Further research is necessary to identify the reasons for such disparities.

Utilization of Paragonix Sherpapak Cardiac Transport System for the Preservation of Donor Hearts After Circulatory Death.

BACKGROUND: Donation after circulatory death (DCD) heart transplantation is being increasingly adopted by transplant centers. The optimal method of DCD heart preservation during transport after in situ thoracoabdominal normothermic regional perfusion (TA-NRP) is not known. METHODS: We evaluated our experience with the Paragonix SherpaPak Cardiac Transport System (SCTS) for the transport of DCD cardiac allografts after TA-NRP recovery between January 2021 and December 2022. We collected and evaluated donor characteristics, allograft ischemic intervals, and recipient baseline demographic and clinical variables, and short-term outcomes. RESULTS: Twelve recipients received DCD grafts recovered with TA-NRP and transported in SCTS during the study period. The median age of 10 male and 2 female donors was 32 years (min 15, max 38). The median duration of functional warm ischemia was 12 minutes (min 8, max 22). Hearts were preserved in SCTS for a median of 158 minutes (min 37, max 224). Median recipient age was 61 years (min 28, max 70). Ten recipients (83%) survived to hospital discharge, with one death attributable to graft dysfunction (8%). The median vasoactive-inotropic (VIS) score at 72 hours post-transplantation of the entire cohort was 6 (min 0, max 15). The median length of intensive care unit stay in hospital survivors was 5 days (min 3, max 17) days and hospital stay 17 days (min 9, max 37). CONCLUSIONS: The Paragonix SCTS provides efficacious preservation of DCD grafts for ≥3.5 hours. Organs transported with this device showed satisfactory post-transplantation function.

Transapical ischemic ventricular septal defect repair with simultaneous centrifugal left ventricular assist device placement: A case report.

INTRODUCTION AND IMPORTANCE: Post-infarct ventricular septal defect (PIVSD) is an often-fatal complication of myocardial infarction despite the use of temporary mechanical circulatory support. CASE PRESENTATION: A 46-year-old male presented with myocardial infarction complicated by PIVSD. Clinical course was characterized by declining systolic function and hemodynamic instability. To provide hemodynamic support, a ventricular assist device was placed at surgical repair of the defect. The patient successfully recovered with no complications 21 months post-repair. He has undergone evaluation for heart transplantation. CLINICAL DISCUSSION: Mortality among patients with PIVSD is high. For patients with cardiogenic shock at the time of defect repair, concomitant ventricular assist device therapy shows promise to decrease morbidity through durable hemodynamic support following surgery. CONCLUSION: Placement of a durable left ventricular assist device (LVAD) at the time of PIVSD repair through a single ventriculotomy may be an effective strategy for this lethal condition.

A Comprehensive Review of Mechanical Circulatory Support Devices.

Treatment strategies to combat cardiogenic shock (CS) have remained stagnant over the past decade. Mortality rates among patients who suffer CS after acute myocardial infarction (AMI) remain high at 50%. Mechanical circulatory support (MCS) devices have evolved as novel treatment strategies to restore systemic perfusion to allow cardiac recovery in the short term, or as durable support devices in refractory heart failure in the long term. Haemodynamic parameters derived from right heart catheterization assist in the selection of an appropriate MCS device and escalation of mechanical support where needed. Evidence favouring the use of one MCS device over another is scant. An intra-aortic balloon pump is the most commonly used short-term MCS device, despite providing only modest haemodynamic support. Impella CP® has been increasingly used for CS in recent times and remains an important focus of research for patients with AMI-CS. Among durable devices, Heartmate® 3 is the most widely used in the USA. Adequately powered randomized controlled trials are needed to compare these MCS devices and to guide the operator for their use in CS. This article provides a brief overview of the types of currently available MCS devices and the indications for their use.

Impact of digoxin utilization on clinical outcomes following left ventricular assist device implantation.

INTRODUCTION: We aimed to assess the impact of digoxin use following left ventricular assist device (LVAD) implantation on clinical outcomes. METHODS: Patients implanted with continuous flow LVADs at a single academic medical center and survived to initial hospital discharge were included in the analysis (n = 346). Clinical events were captured at a maximum of 2 years of follow up. Digoxin use was defined as 30-day continuous use post-LVAD. Negative binomial regression and Kaplan-Meier method were used to assess the association between digoxin use and clinical outcomes. RESULTS: Mean age of the cohort was 56 years (±13) and 23% (79/346) were female sex. Digoxin was used in 144 patients (41.6%) for a median of 268 days (IQR 154, 616). Digoxin use was associated with a significant reduction in cumulative incidence of gastrointestinal bleeding (GIB) (15% vs 26%, p = 0.004). After adjusting for age, hypertension, post-operative hemoglobin, RDW, potassium, and GFR, and use of angiotensin receptor/neprilysin inhibitor, there remained a significant 47% reduction in GIB incidence in patients treated with digoxin. There was no significant difference in cumulative incidence in right ventricular failure (RVF) between the two groups. There was no difference in overall 2-year survival between groups. CONCLUSIONS: Digoxin use was associated with reduction in GIB events, but not in RVF or mortality. Further studies are needed to confirm these findings and to investigate optimal timing and patient population.

Pre-left Ventricular Assist Device Cognition: A Comparison of Rural and Urban Implant Recipients.

Mild cognitive impairment (MCI) is common in patients before left ventricular assist device (LVAD) placement. The consequences of these deficits may differentially impact groups of patients with limited access to postimplantation resources, such as those in rural areas. However, to date, no studies have examined preimplantation cognition in rural and urban patients. Therefore, the purpose of this study was to compare cognition in rural and urban patients before LVAD implantation. This observational cohort study is a secondary analysis of 265 patients undergoing LVAD implantation between July 2004 and June 2019. Preimplantation cognitive function was assessed. Rural-Urban Commuting Area Codes designated rural and urban. Independent-samples Mann-Whitney U tests were used to compare rural and urban cohorts. Subjects were 75.8% (201/265) male, 75.4% (200/265) urban, and 56.6% (±13.2) years old. Rural subjects scored significantly lower on the Mini Mental Status Exam (MMSE) (27 ± 2.20) and Wide Range Achievement Test (WRAT) (32 ± 22.9) compared with urban counterparts (MMSE, 27.6 ± 2.7) (p = 0.009); WRAT (44.4 ± 26.2) (p = 0.02) pre-LVAD. These findings suggest rural patients may have greater MCI before LVAD implantation. Rural LVAD recipients with MCI may require additional intensive education and tailored resource identification before discharge.

Implementation of Multiple Evidence-Based Heart Failure Therapies.

Despite the advancements in the management of heart failure, acute heart failure is one of the most common causes of mortality and morbidity. In light of the financial burden imposed by heart failure hospitalizations on the health care system, this area remains the focus of research, clinical advances, and policy changes aimed at improving the quality of care and outcomes. Despite practice guidelines, high-quality trial data, and consensus statements, barriers to therapy remain. The barriers related to physician, patient, economic, health care system, and logistical factors prevent widespread adoption of available therapeutics. In this review article, we outline guidelines directed therapies for heart failure, challenges associated with their implementation, and potential solutions to these challenges to help reduce mortality and improve clinical outcomes in this patient population.

Reactivation of Cytomegalovirus Following Left Ventricular Assist Device Implantation: A Case-Control Study.

While cytomegalovirus (CMV) reactivation occurs in immunocompetent patients who are critically ill and has been associated with worse outcomes, very few cases of CMV reactivation have been reported following left ventricular assist device (LVAD) implantation. We aimed to evaluate the incidence and risk factors for CMV reactivation following LVAD implantation. Retrospective chart review of patients who had undergone LVAD implantation between July 2004 and December 2018 was performed. Cases with CMV reactivation post-LVAD were randomly matched (1:2) by sex, LVAD type, and implant year with controls utilizing SAS macros. Fisher's exact and paired sample t-tests were performed to evaluate for differences between categorical and continuous variables, respectively. Days to reactivation post-LVAD implantation were calculated in cases, and the corresponding times post-LVAD implantation were determined in control patients for variable comparisons. Survival analysis was performed using the Kaplan-Meier method. Of the 349 patients reviewed, 208 (59.6%) patients were seropositive for CMV before LVAD implantation. Of these 208 patients, eight (3.8%) had CMV reactivation following LVAD implantation. The median time to CMV reactivation following LVAD implantation was 21.5 days (range, 6-177). Six (75%) patients had CMV viremia, and the other two had colitis and pneumonia without viremia. In comparison to controls, patients with CMV had higher creatinine levels (p = 0.039) and higher RDW (p = 0.05) and were more likely to have received steroids within the previous week (p = 0.028) and to have concurrent bacterial infection (p = 0.001). CMV reactivation following LVAD implantation is more frequent than expected. Early testing, diagnosis, and treatment in at-risk patients (i.e., renal failure, steroid use, elevated RDW) might improve clinical outcomes.

Pulmonary Function Testing Pre-heart Transplant Predicts Posttransplant Survival.

Although pulmonary function testing (PFT) is typically performed for heart transplant evaluation, the prognostic utility of PFTs after transplantation is unknown. We evaluated whether PFT parameters were correlated with outcomes following heart transplantation. METHODS: International Society for Heart and Lung Transplantation Thoracic Organ Transplant Registry data were utilized. Survival was assessed using Kaplan-Meier method and compared via log-rank test. Cox proportional hazard modeling was used to evaluate univariate and multivariate predictors of survival. RESULTS: Eight hundred two patients pretransplant PFT data were available for evaluation. Forced expiratory volume in 1 s (FEV1) < 50% predicted (P < 0.0001), and forced vital capacity (FVC) < 50% predicted each had significantly higher mortality (P = 0.001) compared with patients with FEV1 or FVC 50%-80% or >80%. FEV1/FVC < 0.7 was not associated with increased mortality. FEV1 and FVC below 50% both predicted longer lengths of stay (P = 0.028 for FEV1 and P = 0.0075 for FVC). After adjusting for male gender, age, body mass index, smoking history, chronic obstructive pulmonary disease, creatinine, albumin, and total bilirubin, FEV1 < 50% (hazard ratio, 4.91; P < 0.0001; 95% confidence interval, 2.69-8.94) and FVC < 50% (hazard ratio, 2.75; P = 0.003; 95% confidence interval, 1.4-5.4) both remained independent predictors of mortality. CONCLUSIONS: Abnormal pulmonary function (FEV1 or FVC below 50% of predicted) pre-heart transplantation is associated with increased mortality and longer lengths of stay posttransplant.

Impaired Exercise Tolerance Early After Heart Transplantation Is Associated With Development of Cardiac Allograft Vasculopathy.

BACKGROUND: Exercise performance remains limited in some patients after heart transplantation (HTx). The goal of this study was to assess for association between cardiopulmonary exercise test performance at 1 year after HTx and future development of cardiac allograft vasculopathy (CAV). METHODS: Overall 243 HTx recipients performed cardiopulmonary exercise testing at 1 year after HTx. During the median follow-up period of 31 (interquartile range 19;61) months, 76 (32%) patients were diagnosed with CAV (CAV group). RESULTS: The CAV group patients had lower exercise capacity (5.2 ± 1.9 versus 6.5 ± 2.2 metabolic equivalents; P = 0.001) and duration (9.6 ± 3.5 versus 11.4 ± 4.8 min; P = 0.008), lower peak oxygen consumption (VO2) (18.4 ± 5.4 versus 21.4 ± 6.1 mL/kg/min; P = 0.0005), lower normalized peak VO2 (63% ± 18% versus 71% ± 19%; P = 0.007), and higher minute ventilation (VE)/carbon dioxide production (VCO2) (34 ± 5 versus 32 ± 5, P = 0.04). On Cox proportional hazards regression analysis, normalized peak VO2 ≤60%, and VE/VCO2 ≥34 were associated with a high hazard for CAV (HR = 1.8 [95% CI 1.10-4.53, P = 0.03] and 2.5 [95% CI 1.01-8.81, P = 0.04], respectively). The subgroup of patients with both normalized peak VO2 ≤60% and VE/VCO2 ≥34 was at highest risk for development of CAV (HR = 5.2, 95% CI 2.27-15.17, P = 0.001). CONCLUSIONS: Normalized peak VO2 ≤60% and VE/VCO2 ≥34 at 1 year after HTx are associated with the development of CAV.