Implementation of remote monitoring strategies to improve chronic heart failure management.

PURPOSE OF REVIEW: The goal of this review is to describe the current evidence available for remote monitoring devices available for patients with chronic heart failure, and also detail practical clinical recommendations for implementing these tools in daily clinical practice. RECENT FINDINGS: Several devices ranging from sophisticated multiparametric algorithms in defibrillators, implantable pulmonary artery pressure sensors, and wearable devices to measure thoracic impedance can be utilized as important adjunctive tools to reduce the risk of heart failure hospitalization in patients with chronic heart failure. Pulmonary artery pressure sensors provide the most granular data regarding hemodynamic status, while alerts from wearable devices for thoracic impedance and defibrillator-based algorithms increase the likelihood of worsening clinical status while also having high negative predictive value when values are within normal range. SUMMARY: Multiple device-based monitoring strategies are available to reduce longitudinal risk in patients with chronic heart failure. Further studies are needed to best understand a practical pathway to integrate multiple signals of data for early clinical decompensation risk predictionVideo abstract: http://links.lww.com/HCO/A95.

Development and Validation of a Risk Score Predicting Death Without Transplant in Adult Heart Transplant Candidates.

Importance: The US heart allocation system prioritizes medically urgent candidates with a high risk of dying without transplant. The current therapy-based 6-status system is susceptible to manipulation and has limited rank ordering ability. Objective: To develop and validate a candidate risk score that incorporates current clinical, laboratory, and hemodynamic data. Design, Setting, and Participants: A registry-based observational study of adult heart transplant candidates (aged ≥18 years) from the US heart allocation system listed between January 1, 2019, and December 31, 2022, split by center into training (70%) and test (30%) datasets. Adult candidates were listed between January 1, 2019, and December 31, 2022. Main Outcomes and Measures: A US candidate risk score (US-CRS) model was developed by adding a predefined set of predictors to the current French Candidate Risk Score (French-CRS) model. Sensitivity analyses were performed, which included intra-aortic balloon pumps (IABP) and percutaneous ventricular assist devices (VAD) in the definition of short-term mechanical circulatory support (MCS) for the US-CRS. Performance of the US-CRS model, French-CRS model, and 6-status model in the test dataset was evaluated by time-dependent area under the receiver operating characteristic curve (AUC) for death without transplant within 6 weeks and overall survival concordance (c-index) with integrated AUC. Results: A total of 16 905 adult heart transplant candidates were listed (mean [SD] age, 53 [13] years; 73% male; 58% White); 796 patients (4.7%) died without a transplant. The final US-CRS contained time-varying short-term MCS (ventricular assist-extracorporeal membrane oxygenation or temporary surgical VAD), the log of bilirubin, estimated glomerular filtration rate, the log of B-type natriuretic peptide, albumin, sodium, and durable left ventricular assist device. In the test dataset, the AUC for death within 6 weeks of listing for the US-CRS model was 0.79 (95% CI, 0.75-0.83), for the French-CRS model was 0.72 (95% CI, 0.67-0.76), and 6-status model was 0.68 (95% CI, 0.62-0.73). Overall c-index for the US-CRS model was 0.76 (95% CI, 0.73-0.80), for the French-CRS model was 0.69 (95% CI, 0.65-0.73), and 6-status model was 0.67 (95% CI, 0.63-0.71). Classifying IABP and percutaneous VAD as short-term MCS reduced the effect size by 54%. Conclusions and Relevance: In this registry-based study of US heart transplant candidates, a continuous multivariable allocation score outperformed the 6-status system in rank ordering heart transplant candidates by medical urgency and may be useful for the medical urgency component of heart allocation.

Changes in lung fluid levels with variations in the respiratory cycle.

The association between respirophasic variation and lung fluid levels is unknown. Remote dielectric sensing (ReDS™) is a novel non-invasive technology to quantify lung fluid levels. We investigated the change in ReDS values over the course of the respiratory cycle. Patients with clinically stable chronic heart failure at outpatient clinics were prospectively included. ReDS values were measured at three respiratory statuses and compared: (1) at rest with normal breathing, (2) at inspiration, and (3) at expiration. A total of 11 patients were included. Median age was 73 (58, 78) years and 9 were men. ReDS value was 28% (25%, 32%) at rest and decreased significantly with inspiration down to 26% (24%, 30%) (p = 0.004). ReDS value were significantly higher on expiration as 30% (27%, 34%) as compared with rest (p = 0.003). Lung fluid levels in chronic heart failure patients can vary with changes in the respiratory cycle-attention should be paid to what point in the respiratory cycle measurements are taken when interpreting results in each modality, such as chest X-ray (measured at inspiratory status) and right heart catheterization (measured at expiratory status). ReDS system might be a physiologically ideal modality to assess lung fluid amount under natural breathing.

Earlier First Publication Is Associated with More Future Publication.

Participation in clinical research has served clinicians to develop academic careers, as well as to deepen clinical insights, implement evidence-based medicine practices, and even inspire new clinical questions. Early engagement in academic pursuits may better prepare clinicians to maintain long-term research productivity, rather than starting later in their careers.We included medical doctors who graduated from a medical university and retrospectively followed them for 10 years after graduation. The impact of at least one publication within the first 5 years on the achievement of ≥ 5 publications within 10 years was evaluated.A total of 79 medical doctors, including 60 (76%) men, were included. During the first 5 years, 21 (27%) published at least one paper. Overall, 25 (32%) achieved the primary outcome. At least one publication during the first 5 years was an independent predictor of the primary outcome (odds ratio 30.4, 95% confidence interval 2.68-251, P = 0.002). Medical doctors with at least one publication within the first 5 years had significantly higher cumulative 10-year publications compared to no publications within the first 5 years (9 [5, 13] versus 0 [0, 3], P < 0.001).In this retrospective study, we demonstrated that an early involvement in research defined by academic output was associated with higher odds of multiple publications later in a career. Prospective studies to validate our findings by involving young medical doctors in academic pursuits are needed to understand the longitudinal effects of early career academic productivity.

Financial Implication of Sodium Zirconium Cyclosilicate Therapy in Patients with Systolic Heart Failure and Hyperkalemia.

Sodium zirconium cyclosilicate (SZC), a newly-introduced potassium binder, can be used to manage hyperkalemia especially in patients with chronic kidney disease and in those on medical therapy which may raise serum potassium levels. The medication may incur additional costs but may in turn have a significant benefit in the effect of maintaining guideline-directed medical therapy for heart failure. We aimed to investigate the financial impact of SZC therapy in patients with systolic heart failure.Patients with systolic heart failure who received SZC for hyperkalemia between July 2020 and March 2023 were included. In-hospital medical costs were compared between the patients who discontinued SZC and those who continued SZC. For the continue group, the cost of SZC was added. All patients were followed for 2 years or until May 2023.A total of 36 patients (median age 81 years, 56% male, median left ventricular ejection fraction 43%) were included. Total medical costs were significantly lower in the continue group (n = 12) compared to the discontinue group (n = 24) (3.1 [3.1, 6.2] versus 12.1 [3.8, 48.6] × 104 JPY per month, P = 0.039). In the continue group, serum potassium levels were decreased, renin-angiotensin-aldosterone system inhibitor doses were up-titrated, and the left ventricular ejection fraction was increased, whereas these parameters remained unchanged or worsened in the discontinue group.SZC may have the potential to assist in the up-titration of potassium-sparing heart failure-specific medications, prevent readmissions, and minimize medical costs, by preventing recurrent hyperkalemia in patients with systolic heart failure.

Estimation of Small Dense LDL-Cholesterol Levels in Patients with Acute Coronary Syndrome.

Small dense LDL-cholesterol is an established risk factor for atherosclerosis, but it is not routinely measured in clinical practice, and its measurement has not yet been reimbursed. The Sampson equation that uses triglyceride and LDL-cholesterol levels has very recently been proposed to estimate small dense LDL-cholesterol levels. We validated its accuracy in patients with acute coronary syndrome.Serum samples were obtained on admission from hospitalized patients with acute coronary syndrome before heparinization. Small dense LDL-cholesterol levels were measured directly and were also estimated from triglyceride and LDL-cholesterol levels using the Sampson equation. The correlation between the Sampson's equation and direct measurement was investigated.A total of 55 patients were enrolled. The median age was 75 (65, 84) years old, and 35 (64%) were men. There was a moderate correlation between the two methods (r = 0.76, P < 0.001). A lower level of small dense LDL-cholesterol was independently associated with a greater overestimation of the Sampson equation.The Sampson equation is useful for estimating small dense LDL-cholesterol levels in patients with acute coronary syndrome. However, the estimated value may be overestimated in patients with low lipid profiles.

Prognostic Implication of Small Dense LDL-Cholesterol Levels following Acute Coronary Syndrome.

Background and Objectives: Small dense LDL cholesterol is a strong risk factor for atherosclerosis. However, few studies have investigated the impacts of this specific lipid profile on the incident risk of adverse cardiovascular events in patients with acute coronary syndrome. Materials and Methods: Patients with acute coronary syndrome, who underwent revascularization, were included and followed for 2 years. The levels of small dense LDL cholesterol were measured at index discharge (day 0) in the setting of newly administered therapies for secondary prevention, including aspirin and statins, during the index hospitalization. The prognostic impact of small dense LDL-cholesterol levels on the risk of a primary composite endpoint, including cardiac death, non-fatal myocardial infarction, unstable angina pectoris, stroke, and heart failure, was investigated. Results: In total, 46 patients (median 75 (59, 83) years old, 63% men) were included. Median small dense LDL cholesterol was 19.4 (13.5, 23.8) mg/dL at index discharge. All patients initiated statin treatment before the index discharge, with a median LDL-cholesterol level of 77 (64, 109) mg/dL. Small dense LDL-cholesterol level was independently associated with an incremental risk for the primary endpoint (p < 0.05 by adjusting for several potential risk factors, including LDL cholesterol) with a cutoff of 32.6 mg/dL. Conclusions: Small dense LDL-cholesterol level was a significant risk factor for cardiovascular events following presentations of acute coronary syndrome.

An updated estimate of posttransplant survival after implementation of the new donor heart allocation policy.

The Organ Procurement and Transplant Network (OPTN) implemented a new heart allocation policy on October 18, 2018. Published estimates of lower posttransplant survival under the new policy in cohorts with limited follow-up may be biased by informative censoring. Using the Scientific Registry of Transplant Recipients, we used the Kaplan-Meier method to estimate 1-year posttransplant survival for pre-policy (November 1, 2016, to October 31, 2017) and post-policy cohorts (November 1, 2018, to October 31, 2019) with follow-up through March 2, 2021. We adjusted for changes in recipient population over time with a multivariable Cox proportional hazards model. To demonstrate the effect of inadequate follow-up on post-policy survival estimates, we repeated the analysis but only included follow-up through October 31, 2019. Transplant programs transplanted 2594 patients in the pre-policy cohort and 2761 patients in the post-policy cohort. With follow-up through March 2, 2021, unadjusted 1-year posttransplant survival was 90.6% (89.5%-91.8%) in the pre-policy cohort and 90.8% (89.7%-91.9%) in the post-policy cohort (adjusted HR = 0.93 [0.77-1.12]). Ignoring follow-up after October 31, 2019, the post-policy estimate was biased downward (1-year: 82.2%). When estimated with adequate follow-up, 1-year posttransplant survival under the new heart allocation policy was not significantly different.

Decoupling Between Pulmonary Artery Diastolic and Wedge Pressure Following Transcatheter Aortic Valve Replacement.

BACKGROUND: Coexistent pulmonary hypertension with severe aortic stenosis confers a greater risk of mortality for patients undergoing transcatheter aortic valve replacement (TAVR). In this patient population, the impact of significant decoupling between pulmonary artery diastolic and pulmonary capillary wedge, as it relates to clinical risk, remained uncertain.Methods and Results:Patients with severe aortic stenosis who underwent TAVR and completed pre-procedural and post-procedural invasive hemodynamic assessments with right heart catheterization were retrospectively assessed. The impact of post-TAVR decoupling, defined as a pressure difference ≥3 mmHg, on 2-year all-cause mortality or risk of heart failure admission was analyzed. Among 77 included patients (median age 86 years, 23 men), 16 had post-TAVR decoupling. The existence of post-TAVR decoupling was associated with a higher cumulative incidence of the primary endpoint (44% vs. 7%, P=0.001), with an adjusted hazard ratio of 5.87 (95% confidence interval 1.58-21.9, P=0.008). CONCLUSIONS: A greater risk of worse outcomes in those with post-TAVR decoupling was observed. A therapeutic strategy for post-TAVR decoupling and its clinical implication need to be created and investigated in the future.

Anemia and outcomes following left ventricular assist device implantation.

BACKGROUND: Patients with concomitant anemia and congestive heart failure have poor outcomes. The prevalence and clinical risk of anemia in patients receiving durable left ventricular assist devices (LVAD) remain unknown. METHODS: We retrospectively analyzed patients who underwent LVAD implantation between 2014 and 2018. The association between hemoglobin level at the time of index discharge and the one-year composite endpoint of heart failure readmissions or hemocompatibility-related adverse events was investigated. RESULTS: A total of 168 patients (57 [48, 66] years old, 123 males) were included and stratified into a classification of anemia (hemoglobin <9.7 g/dl, N = 99) or non-anemia (N = 69). The anemia group had a higher one-year incidence of the composite endpoint (56% vs 36%, p = .013) with an adjusted hazard ratio of 1.83 (95% confidence interval 1.08-2.82). Patients with anemia also experienced suboptimal bi-ventricular unloading. CONCLUSIONS: Anemia was prevalent in LVAD patients and associated with a greater risk of heart failure and hemocompatibility-related adverse events. The optimal threshold for therapeutic intervention in response to post-LVAD anemia needs further investigation.

Prognostic Implications of Mitral Valve Inflow Pattern Overlap during Ivabradine Therapy.

The prognostic impact of mitral inflow wave overlap during ivabradine therapy in patients with heart failure with reduced ejection fraction (HFrEF) remains to be unknown. Thus, in this study, we have retrospectively examined consecutive inpatients with HFrEF admitted with decompensated heart failure who continued ivabradine following the index discharge. Ideal heart rate (HR), at which echocardiographic mitral inflow wave overlap is theoretically 0, was retrospectively calculated as follows: 96 - 0.13 × (deceleration time [msec]). HR difference was then calculated as follows: actual HR - ideal HR. The association between the HR difference at index discharge and a composite outcome of cardiovascular death and heart failure readmissions was investigated. In total, 16 patients (68 [47, 75] years old, 11 men, median left ventricular ejection fraction 28% [22%, 35%]) were included in this study for analysis. Baseline actual HR was determined to be 88 (81, 93) bpm, whereas the ideal HR was calculated as 75 (73, 76) bpm. Following the initiation of ivabradine, actual HR at index discharge was 75 (64, 84) bpm. Patients with optimal HR (actual HR - ideal HR < ± 10 bpm; n = 9) were found to have experienced a lower incidence of the composite endpoint (40% versus 100%, P = 0.013) compared with those with sub-optimal HR (n = 7) with a hazard ratio of 0.10 (95% confidence interval 0.01-0.91) adjusted for actual HR at index discharge. In conclusion, HR modulation therapy using ivabradine may improve outcomes in patients with HFrEF if individualized ideal HR was achieved.

Implications of Heart Rate in Patients with Left Ventricular Assist Devices.

Optimal heart rate (HR) is a promising therapeutic target in patients with heart failure with reduced ejection fraction. Nevertheless, the implication of optimal HR in patients with left ventricular assist devices (LVAD) remains unknown. The cohort included consecutive patients with sinus rhythm undergoing LVAD implantation between 2014 and 2018. Ideal HR was calculated as follows: 93 - 0.13 × (deceleration time [msec]). The impact of "HR difference," defined as an HR difference between the actual HR at discharge and the calculated ideal HR, on the 1-year mortality and heart failure readmissions was investigated. A total of 143 patients (55 years old, 101 men) was identified and tertiled considering their HR differences: (1) the optimal HR group (n = 49; HR difference < 27 bpm), (2) the suboptimal HR group (n = 47; HR difference = 27-42 bpm), and (3) the nonoptimal HR group; HR difference (n = 47; HR difference > 43 bpm). The nonoptimal HR group had a significantly higher 1-year cumulative incidence of the primary endpoint compared with the optimal HR group (38% versus 16%, P = 0.029) with a hazard ratio of 1.69 (95% confidence interval 1.02-2.57) adjusted for 6 potential confounders. In conclusion, nonoptimized HR negatively affected clinical outcomes in LVAD patients. The implication of deceleration time-guided HR optimization in LVAD patients should be further investigated.

Lung Fluid Volume during Cardiopulmonary Exercise Testing.

Background and Objectives: Cardiopulmonary exercise testing can be used to quantify exercise capacity in patients with heart failure with reduced ejection fraction (HfrEF). Lung fluid levels as measured non-invasively by remote dielectric sensing (ReDSTM), often correlate with intracardiac filling pressures. The change in lung fluid levels in patients with HfrEF during cardiopulmonary exercise testing is unknown. Materials and Methods: Patients with chronic HfrEF who underwent cardiopulmonary exercise testing between October 2021 and March 2022 were prospectively included in this proof-of-concept study, with ReDS values measured before and after testing. Results: Thirteen patients (median age 41 (37, 52) years, 69% men, plasma B-type natriuretic peptide 141 (57, 368) pg/mL) were included. Median peak oxygen consumption was 11.4 (10.7, 14.0) mL/kg/min. During the test, ReDS values increased from 25% to 32% only in one patient on inotropic support, whereas ReDS values remained unchanged in the other 12 patients. The former patient remained hospitalized, whereas the other patients were dischargeable without any new incidence of clinical events during the observational period (median duration 69 (33, 112] days). Conclusions: The ReDS system may be a feasible complementary tool to noninvasively assess the changes in lung fluid levels during cardiopulmonary exercise testing. The clinical implications of ReDS values during exercise needs further investigation.

Change in Lung Fluid Volume during Exercise in Patients with Exercise-Induced Mitral Regurgitation.

Exercise-induced mitral regurgitation (MR) can be diagnosed during stress echocardiography testing. Remote dielectric sensing (ReDSTM) is a noninvasive electromagnetic-based modality to measure lung fluid levels. The change in lung fluid levels in patients with MR during stress echocardiography remains unknown. Patients with symptomatic MR at baseline and suspected worsening exercise-induced MR underwent stress echocardiography. ReDS values were measured before and after the tests. A total of four patients (ages ranging between 74 and 84 years old, three women) underwent stress echocardiography testing using a bicycle ergometer. In patient A, MR effective regurgitant orifice area (EROA) remained unchanged and ReDS values decreased. EROA increased significantly with a small incremental change in ReDS values in patient B and patient C, who underwent valve repair with MitraClip later. Patient D had a mild increase in MR EROA but a considerable increase in ReDS values (from 22% to 32%), and eventually received valve repair with MitraClip. The ReDS system may be a complementary tool to conventional stress echocardiography in the evaluation of clinically significant MR and considering mitral valve intervention.

Between-center variation in high-priority listing status under the new heart allocation policy.

Under the new US heart allocation policy, transplant centers listed significantly more candidates at high priority statuses (Status 1 and 2) with mechanical circulatory support devices than expected. We determined whether the practice change was widespread or concentrated among certain transplant centers. Using data from the Scientific Registry of Transplant Recipients, we used mixed-effect logistic regression to compare the observed listings of adult, heart-alone transplant candidates post-policy (December 2018 to February 2020) to seasonally matched pre-policy cohort (December 2016 to February 2018). US transplant centers (N = 96) listed similar number of candidates in each policy period (4472 vs. 4498) but listed significantly more at high priority status (25.5% vs. 7.0%, p < .001) than expected. Adjusted for candidate characteristics, 91 of 96 (94.8%) centers listed significantly more candidates at high-priority status than expected, with the unexpected increase varying from 4.8% to 50.4% (interquartile range [IQR]: 14.0%-23.3%). Centers in OPOs with highest Status 1A transplant rate pre-policy were significantly more likely to utilize high-priority status under the new policy (OR: 9.73, p = .01). The new heart allocation policy was associated with widespread and significantly variable changes in transplant center practice that may undermine the effectiveness of the new system.

Impact of plasma volume status on mortality following left ventricular assist device implantation.

Worsening systemic congestion is often the central trigger of hospitalization in patients with heart failure. However, accurate assessment of congestion is challenging. The prognostic impact of systemic congestion following durable continuous-flow left ventricular assist device (LVAD) implantation remains unknown. Consecutive patients who received durable continuous-flow LVAD implantation between January 2014 and June 2017 and were followed for 1 year were included. The association of preoperative plasma volume status, which was calculated using patients' body weight and hematocrit and expressed as a deviation from ideal plasma volume, with 1-year mortality following LVAD implantation was investigated. In total, 186 patients (median 57 years and 138 males) were included. Baseline plasma volume status was -30.1% (-37.1%, -19.4%) on median. Eighty-eight patients (47%) had higher plasma volume status (>-29.8%), and their 1-year survival was significantly lower than those without (67% vs. 87%, P = .001). High plasma volume status was an independent predictor of 1-year death with an adjusted hazard ratio of 4.52 (95% confidence interval 1.52-13.5). Baseline systemic congestion, as defined by the high plasma volume status, was associated with higher mortality following durable continuous-flow LVAD implantation. The implication of improving preoperative plasma volume remains an area of needed investigation.

Impact of worsening of aortic insufficiency during HeartMate 3 LVAD support.

Aortic insufficiency remains a difficult to treat and highly morbid condition even in the era of HeartMate 3 left ventricular assist devices (LVADs). The prognostic nature of the longitudinal progression of aortic insufficiency, however, remains unknown. We prospectively collected data on patients who received HeartMate 3 LVAD implantation, who had assessments of aortic insufficiency using a novel Doppler echocardiography obtained at outflow graft at three (baseline) and 6 months postimplant. Patients with moderate or greater aortic insufficiency at baseline were excluded. The risk of aortic insufficiency progression on 1-year death and readmission for heart failure was investigated. In total, 41 patients (median 51 years old and 29 males) were included. All patients had less than moderate aortic insufficiency at baseline. Of them, 22 patients had worsening aortic insufficiency for 3 months following baseline assessments, which was associated with a significantly higher risk of 1-year death or heart failure readmission rate (41% vs. 11%, P = .023) with a hazard ratio of 3.24 (95% confidence interval 1.02-18.5, P = .038) adjusted for device speed at baseline and destination therapy indication. In patients with HeartMate 3 LVADs, progressive aortic insufficiency may be associated with a higher risk of 1-year death or readmission for heart failure. Close monitoring of patients with baseline aortic insufficiency should be considered as a measure to risk-stratify those for future adverse events.

Chronotropic Assessment in Patients with Constrictive Pericarditis.

Management of constrictive pericarditis is often clinically challenging. Heart rate (HR) modulation using ivabradine is associated with improved clinical outcomes in patients with systolic heart failure, although it remains uninvestigated for other clinical purposes. We aimed to assess the impact of HR control in patients with constrictive pericarditis. In this retrospective study, consecutive patients who were diagnosed with constrictive pericarditis were included. Transthoracic echocardiography was performed at index discharge (day 0). The impact of HR difference between actual HR and ideal HR, which was calculated using a formula consisting of deceleration time, on heart failure readmission rates was investigated. A total of 15 patients (73 years old on median, 11 men) with constrictive pericarditis were included. On median, actual HR was 71 bpm and ideal HR was 81 bpm. Heart failure readmission rates were stratified into three groups by the HR difference: (1) optimal HR group satisfying "-10 bpm ≤ HR difference ≤ 10 bpm" (n = 4, 0.067 events per year); (2) lower HR group satisfying "HR difference < -10 bpm" (n = 7, 0.118 events per year, incidence rate ratio 1.98, 95% confidence interval 0.06-61.6); (3) higher HR group satisfying "HR difference > 10 bpm" (n = 4, 0.231 events per year, incidence rate ratio 9.22, 95% confidence interval 0.36-237.8). In conclusion, non-optimized HR was associated with an increased risk of heart failure recurrence in patients with constrictive pericarditis. Prospective assessment of deceleration time-guided HR optimization in patients with constrictive pericarditis is needed.

Association Between Adaptive Servo-Ventilation Therapy and Renal Function.

Cardio-renal syndrome is a challenging clinical entity to manage, and is often associated with increased morbidity and mortality. We hypothesized that adaptive servo-ventilation (ASV), non-invasive positive pressure ventilation that ameliorates systemic/pulmonary congestion, may improve renal function in patients with symptomatic heart failure complicated by the cardio-renal syndrome. Patients with symptomatic congestive heart failure who underwent ASV therapy for over 1 month were included in this retrospective study. The trajectory of the estimated glomerular filtration ratio (eGFR) between the pre-1 month period and the post-one-month period (on ASV) were compared. A total of 81 patients (median 65 years old, 65 men) were included. eGFR decreased during the pre-1 month period from 52.7 (41.7, 64.6) down to 49.9 (37.3, 63.5) mL/minute/1.73 m2 (P < 0.001) whereas we observed an increase following one-month of ASV therapy up to 53.4 (38.6, 68.6) mL/minute/1.73 m2 (P = 0.022). A reduction in furosemide equivalent dose following the initiation of ASV therapy was independently associated with increases in eGFR with an adjusted odds ratio of 13.72 (95% confidence interval 3.40-55.3, P < 0.001). In conclusion, short-term ASV therapy was associated with the preservation of renal function, particularly when the dose of loop diuretics was concomitantly reduced.

HVAD Flow Waveform Estimates Left Ventricular Filling Pressure.

BACKGROUND: HVAD left ventricular assist device flow waveforms provides graphical real-time information linking device performance with invasive hemodynamics. Previous studies have demonstrated a good correlation between the slopes of the ventricular filling phase slope (VFPS) and directly measured pulmonary capillary wedge pressure (PCWP). We aimed to validate the utility of VFPS to estimate PCWP and predict clinical outcomes. METHODS: In this prospective blinded study, screenshots from the HVAD monitor and simultaneous invasive hemodynamic measurements were obtained. Each screenshot was digitized and the VFPS was calculated by 2 independent reviewers who were blinded to the hemodynamic results. The equation PCWP = 7.053 +1.365 × (VFPS) was derived from a previously published dataset and the estimated PCWP was correlated to the actually measured PCWP. RESULTS: One hundred thirty-one sets of simultaneous measurements (VFPS and PCWP) were obtained from 27 HVAD patients (mean age 55 years, 47% male). A previously proposed cutoff of VFPS ≥5.8 L/min/s predicted PCWP ≥ 18 mmHg with 91.5% sensitivity and 95.2% specificity with the area under curve of 0.987. The estimated PCWP significantly correlated with measured PCWP (R2 = 0.65, P < .001) and showed acceptable agreement with measured PCWP. Patients with VFPS ≥ 5.8 L/min/s experienced significantly higher heart failure readmission rates than those without (0.24 vs 0.05 events/y, P < .001). CONCLUSIONS: VFPS of the HVAD flow waveform is a novel noninvasive parameter that can estimate PCWP.