The Association Between Preoperative Pectoralis Muscle Quantity and Outcomes After Cardiac Transplantation.

BACKGROUND: Sarcopenia is underappreciated in advanced heart failure and is not routinely assessed. In patients receiving a left ventricular assist device, preoperative sarcopenia, defined by using computed-tomography (CT)-derived pectoralis muscle-area index (muscle area indexed to body-surface area), is an independent predictor of postoperative mortality. The association between preoperative sarcopenia and outcomes after heart transplant (HT) is unknown. OBJECTIVES: The primary aim of this study was to determine whether preoperative sarcopenia, diagnosed using the pectoralis muscle-area index, is an independent predictor of days alive and out of the hospital (DAOHs) post-transplant. METHODS: Patients who underwent HT between January, 2018, and June, 2022, with available preoperative chest CT scans were included. Sarcopenia was diagnosed as pectoralis muscle-area index in the lowest sex-specific tertile. The primary endpoint was DAOHs at 1 year post-transplant. RESULTS: The study included 169 patients. Patients with sarcopenia (n = 55) had fewer DAOHs compared to those without sarcopenia, with a median difference of 17 days (320 vs 337 days; P = 0.004). Patients with sarcopenia had longer index hospitalizations and were also more likely to be discharged to a facility other than home. In a Poisson regression model, sarcopenia was a significant univariable and the strongest multivariable predictor of DAOHs at 1 year (parameter estimate = -0.17, 95% CI -0.19 to -14; P = < 0.0001). CONCLUSIONS: Preoperative sarcopenia, diagnosed using the pectoralis muscle-area index, is an independent predictor of poor outcomes after HT. This parameter is easily measurable from commonly obtained preoperative CT scans and may be considered in transplant evaluations.

Cardio-Renal-Metabolic Outcomes Associated With the Use of GLP-1 Receptor Agonists After Heart Transplantation.

BACKGROUND: The use of glucagon-like-peptide 1 receptor agonists (GLP1-RA) has dramatically increased over the past 5 years for diabetes mellitus type 2 (T2DM) and obesity. These comorbidities are prevalent in adult heart transplant (HT) recipients. However, there are limited data evaluating the efficacy of this drug class in this population. The aim of the current study was to describe cardiometabolic changes in HT recipients prescribed GLP1-RA at a large-volume transplant center. METHODS: We retrospectively reviewed all adult HT recipients who received GLP1-RA after HT for a minimum of 1-month. Cardiometabolic parameters including body mass index (BMI), lipid panel, hemoglobin A1C, estimated glomerular filtration rate (eGFR), and NT-proBNP were compared prior to initiation of the drug and at most recent follow-up. We also evaluated for significant dose adjustments to immunosuppression after drug initiation and adverse effects leading to drug discontinuation. RESULTS: Seventy-four patients were included (28% female, 53% White, 20% Hispanic) and followed for a median of 383 days [IQR 209, 613] on a GLP1-RA. The majority of patients (n = 56, 76%) were prescribed semaglutide. The most common indication for prescription was T2DM alone (n = 33, 45%), followed by combined T2DM and obesity (n = 26, 35%). At most recent follow-up, mean BMI decreased from 33.3 to 31.5 kg/m2 (p < 0.0001), HbA1C from 7.3% to 6.7% (p = 0.005), LDL from 78.6 to 70.3 mg/dL (p = 0.018) and basal insulin daily dose from 32.6 to 24.8 units (p = 0.0002). CONCLUSION: HT recipients prescribed GLP1-RA therapy showed improved glycemic control, weight loss, and cholesterol levels during the study follow-up period. GLP1-RA were well tolerated and were rarely associated with changes in immunosuppression dosing.

Pre-operative pectoralis muscle area index is associated with biomarkers of inflammation and endotoxemia and predicts clinical outcomes after left ventricular assist device implantation: A cohort study.

BACKGROUND: Pre-left ventricular assist device (LVAD) pectoralis muscle assessment, an estimate of sarcopenia, has been associated with postoperative mortality and gastrointestinal bleeding, though its association with inflammation, endotoxemia, length-of-stay (LOS), and readmissions remains underexplored. METHODS: This was a single-center cohort study of LVAD patients implanted 1/2015-10/2018. Preoperative pectoralis muscle area was measured on chest computed tomography (CT), adjusted for height squared to derive pectoralis muscle area index (PMI). Those with PMI in the lowest quintile were defined as low-PMI cohort; all others constituted the reference cohort. Biomarkers of inflammation (interleukin-6, adiponectin, tumor necrosis factor-α [TNFα]) and endotoxemia (soluble (s)CD14) were measured in a subset of patients. RESULTS: Of the 254 LVAD patients, 95 had a preoperative chest CT (median days pre-LVAD: 7 [IQR 3-13]), of whom 19 (20.0%) were in the low-PMI cohort and the remainder were in the reference cohort. Compared with the reference cohort, the low-PMI cohort had higher levels of sCD14 (2594 vs. 1850 ng/mL; p = 0.04) and TNFα (2.9 vs. 1.9 pg/mL; p = 0.03). In adjusted analyses, the low-PMI cohort had longer LOS (incidence rate ratio 1.56 [95% confidence interval 1.16-2.10], p = 0.004) and higher risk of 90-day and 1-year readmissions (subhazard ratio 5.48 [1.88-16.0], p = 0.002; hazard ratio 1.73 [1.02-2.94]; p = 0.04, respectively). CONCLUSIONS: Pre-LVAD PMI is associated with inflammation, endotoxemia, and increased LOS and readmissions.

The role of vitamin D in cardiovascular disease and COVID-19.

Patients with pre-existing cardiovascular disease (CVD) are at high risk for adverse outcomes with coronavirus disease 2019 (COVID-19). Further, COVID-19 infection is associated with numerous cardiovascular (CV) complications including arrhythmia, myocardial injury, cardiomyopathy, and thrombotic events. Increased susceptibility to COVID-19 and CV complications related to COVID-19 may be in part related to immune dysregulation and inflammation associated with CV disease which is exacerbated with viral infection. Vitamin D plays a major role in immune function and exerts anti-inflammatory effects, which may prove important in the context of CVD and COVID-19. To date, studies have shown minimal benefit for vitamin D supplementation in patients with COVID-19, though there are no studies specific to patients with CVD and related complications. Further, given that vitamin D has important protective effects on the CV system, including augmentation of myocardial contractility and anti-thrombotic effects, it is unknown if supplementation with vitamin D can mitigate CVD complications associated with COVID-19.

The impact of pre-transplant weight loss on survival following cardiac transplantation.

BACKGROUND: Significant weight loss due to cardiac cachexia is an independent predictor of mortality in many heart failure (HF) clinical trials. The impact of significant weight loss while on the waitlist for heart transplant (HT) has yet to be studied with respect to post-transplant survival. METHODS: Adult HT recipients from 2010 to 2021 were identified in the UNOS registry. Patients who experienced an absolute weight change from the time of listing to transplant were included and classified into two groups by percent weight loss from time of listing to time of transplant using a cut-off of 10%. The primary endpoint was 1-year survival following HT. RESULTS: 5951 patients were included in the analysis, of whom 763 (13%) experienced ≥10% weight loss from the time of listing to transplant. Weight loss ≥ 10% was associated with reduced 1-year post-transplant survival (86.9% vs. 91.0%, long-rank p = .0003). Additionally, weight loss ≥ 10% was an independent predictor of 1-year mortality in a multivariable model adjusting for significant risk factors (adjusted HR 1.23, 95% CI 1.04-1.46). In secondary analyses, weight loss ≥ 10% was associated with reduced 1-year survival independent of hospitalized status at time of transplant as well as obesity status at listing (i.e., body mass index [BMI] < 30 kg/m2 and BMI ≥ 30 kg/m2 ). CONCLUSIONS: Preoperative weight loss ≥ 10% is associated with reduced survival in patients listed for HT. Nutrition interventions prior to transplant may prove beneficial in this population.

Parent feeding behavior and child appetite: associations depend on feeding style.

OBJECTIVE: Eating behavior traits measured in early life predict eating behavior and weight trajectories later in development, and may be associated with certain parental feeding behaviors. Our goal was to investigate the relationship between a range of feeding behaviors, and preschoolers' appetitive traits. METHOD: Four hundred thirty-nine parents of UK 3-5 year olds completed scales measuring authoritarian vs. authoritative forms of limiting (Restriction vs. Monitoring) and promoting (Pressuring vs. Prompting) intake, as well as Emotional and Instrumental Feeding. Parents also completed scales measuring child Food responsiveness and Satiety responsiveness. Child BMI z-scores were calculated based on measured heights and weights. RESULTS: Parental Restriction was significantly associated with greater child Food responsiveness (p < .001), but parental Monitoring was not. Parental Pressuring was significantly associated with greater child Satiety responsiveness (p < .001), while parental Prompting was not. Parental Instrumental and Emotional feeding were both associated with greater child Food responsiveness (p < .001). All relationships were independent of child BMI z-score. DISCUSSION: Prospective data are needed to determine whether the parent-child feeding relationships identified here promote, or protect against, the development of eating pathology in children. However, our results suggest that cross-sectional associations depend on the style (e.g., authoritarian vs. authoritative), as well as the type of feeding behavior measured.

Impact of Malnutrition in Patients With Heart Failure and Secondary Mitral Regurgitation: The COAPT Trial.

BACKGROUND: Although malnutrition is associated with poor prognosis in several diseases, its prognostic impact in patients with heart failure (HF) and secondary mitral regurgitation (SMR) is not understood. OBJECTIVES: The purpose of this study was to assess the prevalence and impact of malnutrition in HF patients with severe SMR randomized to transcatheter edge-to-edge repair (TEER) with the MitraClip plus guideline-directed medical therapy (GDMT) vs GDMT alone in the COAPT trial. METHODS: Baseline malnutrition risk was calculated using the validated geriatric nutritional risk index (GNRI) score. Patients were categorized as having "malnutrition" (GNRI ≤98) vs "no malnutrition" (GNRI >98). Outcomes were assessed through 4 years. The primary endpoint of interest was all-cause mortality. RESULTS: Among 552 patients, median baseline GNRI was 109 (IQR: 101-116); 94 (17.0%) had malnutrition. All-cause mortality at 4 years was greater in patients with vs those without malnutrition (68.3% vs 52.8%; P = 0.001). Using multivariable analysis, both baseline malnutrition (adjusted-HR [adj-HR]: 1.37; 95% CI: 1.03-1.82; P = 0.03) and randomization to TEER plus GDMT compared with GDMT alone (adj-HR: 0.65; 95% CI: 0.51-0.82; P = 0.0003) were independent predictors of 4-year mortality. In contrast, GNRI was unrelated to the 4-year rate of heart failure hospitalization (HFH), although TEER treatment reduced HFH (adj-HR: 0.46; 95% CI: 0.36-0.56). The reductions in death (adj-Pinteraction = 0.46) and HFH (adj-Pinteraction = 0.67) with TEER were consistent in patients with and without malnutrition. CONCLUSIONS: Malnutrition was present in 1 of 6 patients with HF and severe SMR enrolled in COAPT and was independently associated with increased 4-year mortality (but not HFH). TEER reduced mortality and HFH in patients with and without malnutrition. (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation [The COAPT Trial] and COAPT CAS [COAPT]; NCT01626079).

Association of Modified Body Mass Index With In-Hospital Outcomes After Intermediate or High-Risk Pulmonary Embolism.

Background: Pulmonary embolism (PE) outcomes are determined by presentation severity and host-related factors. Limited data exist regarding the association of modified body mass index (mBMI), used as a frailty surrogate, with clinical outcomes after treatment for PE. Therefore, we sought to determine the association of mBMI with mortality and bleeding after treatment for intermediate or high-risk PE. Methods: Patients treated for intermediate-risk or high-risk PE at a large academic center between 2013 and 2019 were studied. PE was characterized as intermediate risk (right ventricular compromise) or high risk (hemodynamic compromise) per European Society of Cardiology guidelines. mBMI was defined as the product of serum albumin concentration and body mass index. Patients were stratified according to mBMI quartiles, with low mBMI defined as ≤79, and evaluated for primary end points of in-hospital mortality and bleeding after treatment. A multivariable logistic regression analysis was performed for primary end points. Results: A total of 843 patients were treated for PE. Low mBMI was associated with increased burden of comorbidities and lower rates of interventional or surgical treatment. mBMI was independently associated with mortality (Q1, 22.8%; Q2, 12.4%; Q3, 10.9%; Q4, 6.6%; P = .005) and bleeding (Q1, 20.1%; Q2, 10.1%; Q3, 13.3%; Q4, 11.0%; P = .006). Compared with the lowest mBMI quartile, the highest mBMI quartile was independently associated with lower rates of mortality (OR, 0.28; 95% CI, 0.13-0.58; P < .001) and bleeding (OR, 0.42; 95% CI, 0.23-0.76; P = .004). Conclusions: Low mBMI is prevalent in patients with intermediate-risk and high-risk PE and is independently associated with in-hospital mortality and bleeding after treatment.

Nutrition Assessment and Dietary Interventions in Heart Failure: JACC Review Topic of the Week.

Despite the high prevalence of nutrition disorders in patients with heart failure (HF), major HF guidelines lack specific nutrition recommendations. Because of the lack of standardized definitions and assessment tools to quantify nutritional status, nutrition disorders are often missed in patients with HF. Additionally, a wide range of dietary interventions and overall dietary patterns have been studied in this population. The resulting evidence of benefit is, however, conflicting, making it challenging to determine which strategies are the most beneficial. In this document, we review the available nutritional status assessment tools for patients with HF. In addition, we appraise the current evidence for dietary interventions in HF, including sodium restriction, obesity, malnutrition, dietary patterns, and specific macronutrient and micronutrient supplementation. Furthermore, we discuss the feasibility and challenges associated with the implementation of multimodal nutrition interventions and delineate potential solutions to facilitate addressing nutrition in patients with HF.

Rare Complication of Endoscopic Variceal Therapy: Wide-Complex Tachycardia Associated With Embolization of Glue and Coil.

We present the case of a woman with upper gastrointestinal bleeding secondary to gastric varices requiring endoscopic cyanoacrylate glue and coil embolization. The procedure was complicated by regular, wide-complex tachycardia, with further investigation revealing cardiopulmonary migration of the glue and coil. (Level of Difficulty: Advanced.).

Efficient detection of aortic stenosis using morphological characteristics of cardiomechanical signals and heart rate variability parameters.

Recent research has shown promising results for the detection of aortic stenosis (AS) using cardio-mechanical signals. However, they are limited by two main factors: lacking physical explanations for decision-making on the existence of AS, and the need for auxiliary signals. The main goal of this paper is to address these shortcomings through a wearable inertial measurement unit (IMU), where the physical causes of AS are determined from IMU readings. To this end, we develop a framework based on seismo-cardiogram (SCG) and gyro-cardiogram (GCG) morphologies, where highly-optimized algorithms are designed to extract features deemed potentially relevant to AS. Extracted features are then analyzed through machine learning techniques for AS diagnosis. It is demonstrated that AS could be detected with 95.49-100.00% confidence. Based on the ablation study on the feature space, the GCG time-domain feature space holds higher consistency, i.e., 95.19-100.00%, with the presence of AS than HRV parameters with a low contribution of 66.00-80.00%. Furthermore, the robustness of the proposed method is evaluated by conducting analyses on the classification of the AS severity level. These analyses are resulted in a high confidence of 92.29%, demonstrating the reliability of the proposed framework. Additionally, game theory-based approaches are employed to rank the top features, among which GCG time-domain features are found to be highly consistent with both the occurrence and severity level of AS. The proposed framework contributes to reliable, low-cost wearable cardiac monitoring due to accurate performance and usage of solitary inertial sensors.

Mean Pressure Gradient Prediction Based on Chest Angular Movements and Heart Rate Variability Parameters.

This study presents our recent findings on the classification of mean pressure gradient using angular chest movements in aortic stenosis (AS) patients. Currently, the severity of aortic stenosis is measured using ultra-sound echocardiography, which is an expensive technology. The proposed framework motivates the use of low-cost wearable sensors, and is based on feature extraction from gyroscopic readings. The feature space consists of the cardiac timing intervals as well as heart rate variability (HRV) parameters to determine the severity of disease. State-of-the-art machine learning (ML) methods are employed to classify the severity levels into mild, moderate, and severe. The best performance is achieved by the Light Gradient-Boosted Machine (Light GBM) with an F1-score of 94.29% and an accuracy of 94.44%. Additionally, game theory-based analyses are employed to examine the top features along with their average impacts on the severity level. It is demonstrated that the isovolumetric contraction time (IVCT) and isovolumetric relaxation time (IVRT) are the most representative features for AS severity.Clinical Relevance- The proposed framework could be an appropriate low-cost alternative to ultra-sound echocardiography, which is a costly method.

Anticoagulation with warfarin compared to novel oral anticoagulants for atrial fibrillation in adults with transthyretin cardiac amyloidosis: comparison of thromboembolic events and major bleeding.

BACKGROUND: Atrial fibrillation (AF) is common in patients with transthyretin cardiac amyloidosis (ATTR-CA). The optimal strategy to prevent strokes in patients with ATTR-CA and AF is unknown. OBJECTIVES: To compare outcomes in patients with ATTR-CA and AF treated with warfarin versus novel oral anticoagulants (NOACs). METHODS: This study was a retrospective analysis of patients with ATTR-CA stratified by presence or absence of AF and anticoagulation therapy. The primary outcome included a time to event analysis for the combined outcomes of stroke, transient ischaemic attack (TIA), major bleed, or death. RESULTS: Of 290 patients, 217 patients (74.8%) had AF. Of those with AF (n = 217), 78 (35.9%) patients received warfarin compared with 116 (53.5%) patients who received NOACs. There were 17 thrombotic events, all in those diagnosed with AF compared with none in the patients without AF (p = .01). Over a mean follow-up of 2.4 years (range 0.1-12) there was no difference in primary outcome between those with AF treated with warfarin compared with NOACs (p = .35). CONCLUSION: Patient with ATTR-CA and AF are at increased risk for stroke compared to patients with ATTR-CA and without AF. Thrombotic events and major bleeds did not differ between those who received warfarin and NOACs.

Relation between Modified Body Mass Index and Adverse Outcomes after Aortic Valve Implantation.

We aimed to investigate the relationship of modified body mass index (mBMI), the product of BMI and serum albumin, with survival after transcatheter (TAVI) and surgical aortic valve implantation (SAVI). Frailty is associated with poor outcomes after TAVI and SAVI for severe aortic stenosis (AS). However, clinical frailty is not routinely measured in clinical practice due to the cumbersome nature of its assessment. Modified BMI is an easily measurable surrogate for clinical frailty that is associated with survival in elderly cohorts with non-valvular heart disease. We utilized individual patient-level data from a pooled database of the Placement of Aortic Transcatheter Valves (PARTNER) trials from the PARNTER1, PARTNER2 and S3 cohorts. We estimated cumulative mortality at 1 year for quartiles of mBMI with the Kaplan-Meier method and compared them with the log-rank test. We performed Cox proportional hazards modeling to assess the association of mBMI strata with 1-year mortality adjusting for baseline clinical characteristics. A total of 6593 patients who underwent TAVI or SAVI (mean age 83±7.3 years, 57% male) were included. mBMI was independently associated with all-cause one-year mortality with the lowest mBMI quartile as most predictive (HR 2.33, 95% CI 1.80-3.02, p < 0.0001). Notably, mBMI performed as well as clinical frailty index to predict 1-year mortality in this cohort. In conclusion, modified BMI predicts 1-year survival after both TAVI and SAVI. Given that it performed similar to the clinical frailty index, it may be used as a clinical tool for assessment of frailty prior to valve implantation.

The quintessential form of diastolic heart failure in older adults: Wild type transthyretin cardiac amyloidosis.

Wild-type transthyretin cardiac amyloidosis (ATTRwt) is now recognized as a common cause of heart failure with preserved ejection fraction (HFpEF). In this review, we aim to describe the unique epidemiologic, pathophysiologic, and clinical features associated with ATTwt cardiac amyloidosis. Compared to other etiologies of HFpEF, ATTRwt cardiac amyloidosis affects almost exclusively older adults, demonstrating a characteristic age-dependent penetrance that impacts both the diagnosis and treatment of the disease. In addition, ATTR cardiac amyloidosis demonstrates a unique pathophysiology in contrast to other etiologies of HFpEF, which results in a characteristic phenotype that can raise suspicion for ATTRwt cardiac amyloid in the appropriate demographic. With these distinguishing features in mind, we aim to describe the specific signs, symptoms, and imaging characteristics associated with ATTRwt cardiac amyloidosis, including the role of nuclear scintigraphy that has essentially eliminated the need for biopsy in most patients with suspected disease. Finally, we review the evidence behind the available therapeutic agents, as well as those under investigation, which will change the way we manage older patients with ATTRwt cardiac amyloidosis in the coming years.

Markers of nutritional status and inflammation in transthyretin cardiac amyloidosis: association with outcomes and the clinical phenotype.

Background: Patients with transthyretin (TTR) cardiac amyloidosis demonstrate cardiac cachexia with progression of their cardiomyopathy, which is characterised by malnutrition and a heightened inflammatory state. How best to measure this condition is less well characterised. We investigated differences in survival among patients with ATTR cardiac amyloidosis by nutritional status as defined by modified BMI (mBMI) and by inflammatory state as defined by serum uric acid.Methods and results: This study was a retrospective analysis of patients diagnosed with ATTR cardiac amyloidosis at a single tertiary medical centre. Baseline characteristics were compared by nutritional status as measured by mBMI and by inflammatory state as measured by serum uric acid. Kaplan-Meier survival analyses were used to compare nutritional status and inflammatory status for the composite outcome of death. Cox proportional hazards modelling was used to assess predictors of death in this cohort. Three hundred patients (mean age 75 ± 11) years, 84.3% male) were included. Those with low mBMI (<1185 kg/m2 g/L) had shorter time to death (5.4 vs. 6.8 years, log rank p = .045) and those with elevated serum uric acid (>8.8 mg/dL) had shorter time to death (4.9 vs. 7.7 years, log rank p < .0001). Those with both low mBMI and elevated serum uric acid had the shortest time to death (4.3 years, log rank p = .005). In this cohort, mBMI was not a univariate predictor of death though there was a trend towards significance (HR 0.92, per 100 kg/m2 g/L, 95% CI 0.828-1.016, p = .099). Serum uric acid was a univariate predictor of death (HR 1.27 per 1 mg/dL, 95% CI 1.114-1.455, p < .001). In multivariate Cox analysis, this association remained significant (HR 1.31 per 1 mg/dL increase, 95% CI 1.096-1.560, p = .003) as well as in a separate stepwise model controlling for potential confounders including daily diuretic use, uric acid lowering therapy, and renal dysfunction.Conclusions: Both nutritional status as measured by mBMI and inflammation as measured by serum uric acid are associated with survival in patients with TTR cardiac amyloidosis however only serum uric acid is an independent predictor of death.

Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 that has significant implications for the cardiovascular care of patients. First, those with COVID-19 and pre-existing cardiovascular disease have an increased risk of severe disease and death. Second, infection has been associated with multiple direct and indirect cardiovascular complications including acute myocardial injury, myocarditis, arrhythmias, and venous thromboembolism. Third, therapies under investigation for COVID-19 may have cardiovascular side effects. Fourth, the response to COVID-19 can compromise the rapid triage of non-COVID-19 patients with cardiovascular conditions. Finally, the provision of cardiovascular care may place health care workers in a position of vulnerability as they become hosts or vectors of virus transmission. We hereby review the peer-reviewed and pre-print reports pertaining to cardiovascular considerations related to COVID-19 and highlight gaps in knowledge that require further study pertinent to patients, health care workers, and health systems.