Remote Dielectric Sensing Before and After Discharge in Patients With ADHF: The ReDS-SAFE HF Trial.

BACKGROUND: Incomplete treatment of congestion often leads to worsening heart failure (HF). The remote dielectric sensing (ReDS) system is an electromagnetic energy-based technology that accurately quantifies changes in lung fluid concentration noninvasively. OBJECTIVES: This study sought to assess whether an ReDS-guided strategy during acutely decompensated HF hospitalization is superior to routine care for improving outcomes at 1 month postdischarge. METHODS: ReDS-SAFE HF (Use of ReDS for a SAFE discharge in patients with acute Heart Failure) was an investigator-initiated, multicenter, single-blind, randomized, proof-of-concept trial in which 100 patients were randomized to a routine care strategy, with discharge criteria based on current clinical practice, or an ReDS-guided decongestion strategy, with discharge criteria requiring an ReDS value of ≤35%. ReDS measurements were performed daily and at a 7-day follow-up visit, with patients and treating physicians in the routine care arm blinded to the results. The primary outcome was a composite of unplanned visits for HF, HF rehospitalization, or death at 1 month after discharge. RESULTS: The mean age was 67 ± 14 years, and 74% were male. On admission, left ventricular ejection fraction was 37% ± 16%, and B-type natriuretic peptide was 940 pg/L (Q1-Q3: 529-1,665 pg/L). The primary endpoint occurred in 10 (20%) patients in the routine care group and 1 (2%) in the ReDS-guided strategy group (log-rank P = 0.005). The ReDS-guided strategy group experienced a lower event rate, with an HR of 0.094 (95% CI: 0.012-0.731; P = 0.003), and a number of patients needed to treat of 6 to avoid an event (95% CI: 3-17), mainly resulting from a decrease in HF readmissions. The median length of stay was 2 days longer in the ReDS-guided group vs the routine care group (8 vs 6; P = 0.203). CONCLUSIONS: A ReDS-guided strategy to treat congestion improved 1-month prognosis postdischarge in this proof-of-concept study, mainly because of a decrease of the number of HF readmissions. (Use of ReDS for a SAFE discharge in patients with acute Heart Failure [ReDS-SAFE HF]; NCT04305717).

The Relevance of Implementing the Systematic Screening of Perioperative Myocardial Injury in Noncardiac Surgery Patients.

Perioperative myocardial injury (PMI) is a common cardiac complication. Recent guidelines recommend its systematic screening using high-sensitivity cardiac troponin (hs-cTn). However, there is limited evidence of local screening programs. We conducted a prospective, single-center study aimed at assessing the feasibility and outcomes of implementing systematic PMI screening. Hs-cTn concentrations were measured before and after surgery. PMI was defined as a postoperative hs-cTnT of ≥14 ng/L, exceeding the preoperative value by 50%. All patients were followed-up during the hospitalization, at one month and one year after surgery. The primary outcome was the incidence of death and major cardiovascular and cerebrovascular events (MACCE). The secondary outcomes focused on the individual components of MACCE. We included two-thirds of all eligible high-risk patients and achieved almost complete compliance with follow-ups. The prevalence of PMI was 15.7%, suggesting a higher presence of cardiovascular (CV) antecedents, increased perioperative CV complications, and higher preoperative hs-cTnT values. The all-cause death rate was 1.7% in the first month, increasing up to 11.2% at one year. The incidence of MACCE was 9.5% and 8.6% at the same time points. Given the observed elevated frequencies of PMI and MACCE, implementing systematic PMI screening is recommendable, particularly in patients with increased cardiovascular risk. However, it is important to acknowledge that achieving optimal screening implementation comes with various challenges and complexities.

Subclinical congestion assessed by lung ultrasound in ST segment elevation myocardial infarction.

OBJECTIVE: We evaluated the prognostic value of subclinical congestion assessed by lung ultrasound (LUS) in patients admitted for ST segment elevation myocardial infarction (STEMI). METHODS: This was a multicentre study that prospectively enrolled 312 patients admitted for STEMI without signs of heart failure (HF) at admission. LUS was performed during the first 24 hours after revascularisation and classified patients as having either wet lung (three or more B-lines in at least one lung field) or dry lung. The primary endpoint was a composite of acute HF, cardiogenic shock or death during hospitalisation. The secondary endpoint was a composite of readmission for HF or new acute coronary syndrome or death during 30-day follow-up. Zwolle score was calculated in all patients to assess predictive improvement by adding the result of the LUS to this score. RESULTS: 14 patients (31.1%) in the wet lung group presented the primary endpoint vs 7 (2.6%) in the dry lung group (adjusted RR 6.0, 95% CI 2.3 to 16.2, p=0.007). The secondary endpoint occurred in five patients (11.6%) in the wet lung group and in three (1.2%) in the dry lung group (adjusted HR 5.4, 95% CI 1.0 to 28.7, p=0.049). Addition of LUS improved the ability of the Zwolle score to predict the follow-up composite endpoint (net reclassification improvement 0.99). LUS showed a very high negative predictive value in predicting in-hospital and follow-up endpoints (97.4% and 98.9%, respectively). CONCLUSION: Early subclinical pulmonary congestion identified by LUS in patients with Killip I STEMI at hospital admission is associated with adverse outcomes during hospitalisation and 30-day follow-up.

Do Women Physicians Accept and Follow Heart Failure Guidelines More Than Men?

PURPOSE OF REVIEW: Our aim was to assess the degree of acceptance of the European Clinical Practice Guidelines (CPG) on heart failure (HF) among Spanish physicians according to sex. This was a cross-sectional study, employing Google Forms, conducted by a group of HF experts from the Region of Madrid (Spain), between November 2021 and February 2022, among specialists and residents of Cardiology, Internal Medicine, and Primary Care from Spain. RECENT FINDINGS: A total of 387 physicians-173 women (44.7%)-from 128 different centers completed the survey. Compared to men, women were significantly younger (38.2 ± 9.1 years vs. 40.6 ± 11.2 years; p = 0.024) and had fewer years of clinical practice (12.1 ± 8.1 years vs. 14.5 ± 10.7 years; p = 0.014). Briefly, women and men had a positive opinion of the guidelines and thought that implementing quadruple therapy is feasible in less than 8 weeks. Women followed more frequently than men the new paradigm of "4 pillars at lowest doses" and considered more frequently the establishment of quadruple therapy before implanting a cardiac device. Although they agreed about "low blood pressure" as the major limitation for achieving quadruple therapy in heart failure with reduced ejection fraction, there were discrepancies on the second most frequent barrier, and women were more proactive when initiating SGLT2 inhibitors. In a large survey including nearly 400 doctors from all over Spain to provide real-world opinion on 2021 ESC HF Guidelines and experience with SGLT2 inhibitors, women follow more frequently the new paradigm of "4 pillars at lowest doses", consider more frequently the establishment of quadruple therapy before implanting a cardiac device, and were more proactive when initiating SGLT2 inhibitors. Further studies confirming an association of sex with a better compliance of HF guidelines are needed.

Myocardial injury after major non-cardiac surgery evaluated with advanced cardiac imaging: a pilot study.

BACKGROUND: Myocardial injury after non-cardiac surgery (MINS) is a frequent complication caused by cardiac and non-cardiac pathophysiological mechanisms, but often it is subclinical. MINS is associated with increased morbidity and mortality, justifying the need to its diagnose and the investigation of their causes for its potential prevention. METHODS: Prospective, observational, pilot study, aiming to detect MINS, its relationship with silent coronary artery disease and its effect on future adverse outcomes in patients undergoing major non-cardiac surgery and without postoperative signs or symptoms of myocardial ischemia. MINS was defined by a high-sensitive cardiac troponin T (hs-cTnT) concentration > 14 ng/L at 48-72 h after surgery and exceeding by 50% the preoperative value; controls were the operated patients without MINS. Within 1-month after discharge, cardiac computed tomography angiography (CCTA) and magnetic resonance imaging (MRI) studies were performed in MINS and control subjects. Significant coronary artery disease (CAD) was defined by a CAD-RADS category ≥ 3. The primary outcomes were prevalence of CAD among MINS and controls and incidence of major cardiovascular events (MACE) at 1-year after surgery. Secondary outcomes were the incidence of individual MACE components and mortality. RESULTS: We included 52 MINS and 12 controls. The small number of included patients could be attributed to the study design complexity and the dates of later follow-ups (amid COVID-19 waves). Significant CAD by CCTA was equally found in 20 MINS and controls (30% vs 33%, respectively). Ischemic patterns (n = 5) and ischemic segments (n = 2) depicted by cardiac MRI were only observed in patients with MINS. One-year MACE were also only observed in MINS patients (15.4%). CONCLUSION: This study with advanced imaging methods found a similar CAD frequency in MINS and control patients, but that cardiac ischemic findings by MRI and worse prognosis were only observed in MINS patients. Our results, obtained in a pilot study, suggest the need of further, extended studies that screened systematically MINS and evaluated its relationship with cardiac ischemia and poor outcomes. Trial registration Clinicaltrials.gov identifier: NCT03438448 (19/02/2018).

Time course, factors related to, and prognostic impact of venoarterial extracorporeal membrane flow in cardiogenic shock.

AIMS: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is currently one of the most used devices in refractory cardiogenic shock. However, there is a lack of evidence on how to set the 'optimal' flow. We aimed to describe the evolution of VA-ECMO flows in a cardiogenic shock population and determine the risk factors of 'high-ECMO flow'. METHODS AND RESULTS: A 7 year database of patients supported with VA-ECMO was used. Based on the median flow during the first 48 h of the VA-ECMO run, patients were classified as 'high-flow' or 'low-flow', respectively, when median ECMO flow was ≥3.6 or <3.6 L/min. Outcomes included rates of ventilator-associated pneumonia, ECMO-related complications, days on ECMO, days on mechanical ventilation, intensive care unit and hospitalization lengths of stay, and in-hospital and 60 day mortality. Risk factors of high-ECMO flow were assessed using univariate and multivariate cox regression. The study population included 209 patients on VA-ECMO, median age was 51 (40-59) years, and 78% were males. The most frequent aetiology leading to cardiogenic shock was end-stage dilated cardiomyopathy (57%), followed by acute myocardial infarction (23%) and fulminant myocarditis (17%). Among the 209 patients, 105 (50%) were classified as 'high-flow'. This group had a higher rate of ischaemic aetiology (16% vs. 30%, P = 0.023) and was sicker at admission, in terms of worse Simplified Acute Physiology Score II score [40 (26-58) vs. 56 (42-74), P < 0.001], higher lactate [3.6 (2.2-5.8) mmol/L vs. 5.2 (3-9.7) mmol/L, P < 0.001], and higher aspartate aminotransferase [97 (41-375) U/L vs. 309 (85-939) U/L, P < 0.001], among others. The 'low-flow' group had less ventilator-associated pneumonia (40% vs. 59%, P = 0.007) and less days on mechanical ventilation [4 (1.5-7.5) vs. 6 (3-12) days, P = 0.009]. No differences were found in lengths of stay or survival according to the ECMO flow. The multivariate analysis showed that risk factors independently associated with 'high-flow' were mechanical ventilation at cannulation [odds ratio (OR) 3.9, 95% confidence interval (CI) 2.1-7.1] and pre-ECMO lactate (OR 1.1, 95% CI 1.0-1.2). CONCLUSIONS: In patients with refractory cardiogenic shock supported with VA-ECMO, sicker patients had higher support since early phases, presenting thereafter higher rates of ventilator-associated pneumonia but similar survival compared with patients with lower flows.

Incremental prognostic value of lung ultrasound on contemporary heart failure risk scores.

Introduction: Over the last decades, several scores have been developed to aid clinicians in assessing prognosis in patients with heart failure (HF) based on clinical data, medications and, ultimately, biomarkers. Lung ultrasound (LUS) has emerged as a promising prognostic tool for patients when assessed at discharge after a HF hospitalization. We hypothesized that contemporary HF risk scores can be improved upon by the inclusion of the number of B-lines detected by LUS at discharge to predict death, urgent visit, or HF readmission at 6- month follow-up. Methods: We evaluated the discrimination improvement of adding the number of B-lines to 4 contemporary HF risk scores (Get with the Guidelines -GWTG-, MAGGIC, Redin-SCORE, and BCN Bio-HF) by comparing the change in the area under the receiver operating curve (AUC), the net reclassification index (NRI), and the integrated discrimination improvement (IDI). The population of the study was constituted by the 123 patients enrolled in the LUS-HF trial, adjusting the analyses by the intervention. Results: The AUC of the GWTG score increased from 0.682 to 0.789 (p = 0.02), resulting in a NRI of 0.608 and an IDI of 0.136 (p < 0.05). Similar results were observed when adding the number of B-lines to the MAGGIC score, with an AUC that increased from 0.705 to 0.787 (p < 0.05). This increase translated into a NRI of 0.608 and an IDI of 0.038 (p < 0.05). Regarding Redin-SCORE at 1-month and 1-year, the AUC increased from 0.714 to 0.773 and from 0.681 to 0.757, although it did not reach statistical significance (p = 0.08 and p = 0.06 respectively). Both IDI and NRI were significantly improved (0.093 and 0.509 in the 1-month score, p < 0.05; 0.056 and 0.111 in the 1-year score, p < 0.05). Lastly, the AUC for the BCN Bio-HF score increased from 0.733 to 0.772, which was statistically non-significant, with a NRI value of 0.363 (p = 0.06) and an IDI of 0.092 (p < 0.05). Conclusion: Adding the results of LUS evaluated at discharge improved the predictive value of most of the contemporary HF risk scores. As it is a simple, fast, and non-invasive test it may be recommended to assess prognosis at discharge in HF patients.

Gender Differences in Cardiogenic Shock Patients: Clinical Features, Risk Prediction, and Outcomes in a Hub Center.

Introduction: There is scarce knowledge about gender differences in clinical presentation, management, use of risk stratification tools and prognosis in cardiogenic shock (CS) patients. Purpose: The primary endpoint was to investigate the differences in characteristics, management, and in-hospital mortality according to gender in a cohort of CS patients admitted to a tertiary hub center. The secondary endpoint was to evaluate the prognostic performance of the Society of Cardiovascular Angiography and Interventions (SCAI) classification in predicting in-hospital mortality according to sex. Methods: This is a retrospective single-Center cohort study of CS patients treated by a multidisciplinary shock team between September 2014 and December 2020. Baseline characteristics and clinical outcomes according to gender were registered. Discrimination of SCAI classification was assessed using the area under the receiver operating characteristic curve (AUC). Results: Overall, 163 patients were included, 39 of them female (24%). Mean age of the overall cohort was 55 years (44-62), similar between groups. Compared with men, women were less likely to be smokers and the prevalence of COPD and diabetes mellitus was significantly lower in this group (p < 0.05). Postcardiotomy (44 vs. 31%) and fulminant myocarditis (13 vs. 2%) were more frequent etiologies in females than in males (p = 0.01), whereas acute myocardial infarction was less common among females (13 vs. 33%). Regarding management, the use of temporary mechanical circulatory support, mechanical ventilation, or renal replacement therapy was frequent and no different between the groups (88, 87, and 49%, respectively, in females vs. 42, 91, and 41% in males, p > 0.05). In-hospital survival in the overall cohort was 53%, without differences between groups (52% in females vs. 55% in males, p = 0.76). Most of the patients (60.7%) were in SCAIE at presentation without differences between sexes. The SCAI classification showed a moderate ability for predicting in-hospital mortality (overall, AUC: 0.653, 95% CI 0.582-0.725). The AUC was 0.636 for women (95% CI 0.491-0.780) and 0.658 for men (95% CI 0.575-0.740). Conclusions: Only one in four of patients treated at a dedicated CS team were female. This may reflect differences in prevalence of severe heart disease at young (<65) ages, although a patient-selection bias cannot be ruled out. In this very high-risk CS population of multiple etiologies, overall, in-hospital survival was slightly above 50% and showed no differences between sexes. Treatment approaches, procedures, and SCAI risk stratification performance did not show gender disparities among treated patients.

Endomyocardial biopsy-confirmed myocarditis and inflammatory cardiomyopathy: clinical profile and prognosis.

INTRODUCTION AND OBJECTIVES: Endomyocardial biopsy (EMB) is the only technique able to establish an etiological diagnosis of myocarditis or inflammatory cardiomyopathy (ICM). The aim of this study was to analyze the clinical profile, outcomes, and prognostic factors of patients with suspected myocarditis/ICM undergoing EMB. METHODS: We retrospectively analyzed the clinical characteristics, histological findings, and follow-up data of all patients with suspected myocarditis or ICM who underwent EMB between 1997 and 2019 in a Spanish tertiary hospital. The diagnostic yield was compared using the Dallas criteria vs immunohistochemical criteria (IHC). RESULTS: A total of 99 patients underwent EMB (67% male; mean age, 42±15 years; mean left ventricular ejection fraction [LVEF], 34%±14%). Myocarditis or ICM was confirmed in 28% with application of the Dallas criteria and in 54% with the IHC criteria (P <.01). Lymphocytic myocarditis was diagnosed in 47 patients, eosinophilic myocarditis in 6, sarcoidosis in 3, and giant cell myocarditis in 1 patient. After a median follow-up of 18 months, 23 patients (23%) required heart transplant (HTx), a left ventricular assist device (LVAD), and/or died. Among the patients with IHC-confirmed myocarditis, 21% required HTx/LVAD or died vs 7% of those without inflammation (P=.056). The factors associated with a worse prognosis were baseline LVEF ≤ 30%, left ventricular end-diastolic diameter ≥ 60mm, and NYHA III-IV, especially in the presence of inflammation. CONCLUSIONS: EMB allows an etiological diagnosis in more than half of patients with suspected myocarditis/ICM when IHC techniques are used. IHC-confirmed inflammation adds prognostic value and helps to identify patients with a higher probability of developing complications.

Usefulness of Serial Multiorgan Point-of-Care Ultrasound in Acute Heart Failure: Results from a Prospective Observational Cohort.

Background and Objectives: Acute heart failure (AHF) is a common disease and a cause of high morbidity and mortality, constituting a major health problem. The main purpose of this study was to determine the impact of multiorgan ultrasound in identifying pulmonary hypertension (PH), a major prognostic factor in patients admitted due to AHF, and assess whether there are significant changes in the venous excess ultrasonography (VE × US) score or femoral vein Doppler at discharge. Materials and Methods: Patients were evaluated with a standard protocol of lung ultrasound, echocardiography, inferior vena cava (IVC) and hepatic, portal, intra-renal and femoral vein Doppler flow patterns at admission and on the day of discharge. Results: Thirty patients were enrolled during November 2021. The mean age was seventy-nine years (Standard Deviation-SD 13.4). Seven patients (23.3%) had a worsening renal function during hospitalization. Regarding ultrasound findings, VE × US score was calculated at admission and at discharge, unexpectedly remaining unchanged or even worsened (21 patients, 70.0%). The area under the curve for the lung score was 83.9% (p = 0.008), obtaining a cutoff value of 10 that showed a sensitivity of 82.6% and a specificity of 71.4% in the identification of intermediate and high PH. It was possible to monitor significant changes between both exams on the lung score (16.5 vs. 9.3; p < 0.001), improvement in the hepatic vein Doppler pattern (2.4 vs. 2.1; p = 0.002), improvement in portal vein Doppler pattern (1.7 vs. 1.4; p = 0.023), without significant changes in the intra-renal vein Doppler pattern (1.70 vs. 1.57; p = 0.293), VE × US score (1.3 vs. 1.1; p = 0.501), femoral vein Doppler pattern (2.4 vs. 2.1; p = 0.161) and IVC collapsibility (2.0 vs. 2.1; p = 0.420). Conclusions: Our study results suggest that performing serial multiorgan Point-of-Care ultrasound can help us to better identify high and intermediate probability of PH patients with AHF. Currently proposed multi-organ, venous Doppler scanning protocols, such as the VE × US score, should be further studied before expanding its use in AHF patients.

The Interaction of Amiodarone and Continuous-flow Left Ventricular Assist Device Use in Risk of Severe Primary Graft Dysfunction Following Heart Transplantation.

BACKGROUND: Primary graft dysfunction (PGD) increases morbidity and mortality after heart transplant. Here we investigated (1) the association of continuous-flow left ventricular assist device (CF-LVAD), amiodarone, and severe PGD and (2) the safety of amiodarone discontinuation in CF-LVAD patients. METHODS: Retrospective, single-center study of heart transplant recipients was conducted to investigate the association of risk factors and severe PGD. Patients were grouped into 4 groups based on the presence (denoted +) or absence (denoted -) of amiodarone and CF-LVAD. Prospective amiodarone discontinuation was undertaken to investigate its safety in a cohort of CF-LVAD patients. Study endpoints were severe PGD and recurrence of arrhythmia. RESULTS: Severe PGD was strongly associated with CF-LVAD and amiodarone use, and its prevalence is highest if both risk factors were present (CF-LVAD-/amiodarone - 1.5%, CF-LVAD -/amiodarone+ 4.5%, CF-LVAD+/amiodarone - 7.1%, CF-LVAD+/amiodarone+ 21.8%; P < 0.01). The product of every 1-y additional CF-LVAD support by every 100 mg amiodarone was associated with severe PGD (adjusted odds ratio, 1.43; 95% confidence interval, 1.15-1.78; P < 0.01). Amiodarone was prospectively discontinued in 28 CF-LVAD patients. Of them, 6 patients had recurrence of arrhythmia requiring treatment or heart failure admission. There were no deaths. Nine patients in whom amiodarone had been discontinued had heart transplants with no severe PGD. CONCLUSIONS: Amiodarone and CF-LVAD were independently associated with severe PGD. The combination of both risk factors was associated with a higher prevalence of severe PGD. Amiodarone discontinuation was associated with recurrence of arrhythmia in 6 CF-LVAD patients. There was no mortality associated with amiodarone discontinuation.

Exploring the potential relationship between collagen cross-linking and impaired myocardial relaxation in Marfan syndrome: An observational study using serum biomarkers.

BACKGROUND: Increased collagen cross-linking (CCL) has been described in hypertensive cardiomyopathy by means of reduced serum ratio of serum carboxyterminal telopeptide of collagen type I (CITP) to matrix metalloproteinase-1 (MMP1). Previous studies have demonstrated the existence of primary impaired diastole in patients with Marfan syndrome (MFS), but little is known about the pathophysiology of this condition. METHODS: 60 MFS patients (without previous cardiovascular surgery or significant valvular regurgitation) and 24 healthy controls (age and sex-matched) were enrolled. All participants underwent a comprehensive transthoracic echocardiographic study, including left atrial and left ventricular speckle-tracking strain analysis. CITP and MMP1 were measured in peripheral blood. RESULTS: All participants had normal diastolic function according to guidelines. Peak left atrial strain in the reservoir phase (LASr) was significantly reduced in the MFS cohort compared to controls (32.2 ± 9.4 vs 43.9 ± 7.0%; p < 0.001). Serum CITP and CITP:MMP1 ratio were lower among MFS patients, showing significant correlations with LASr (R = 0.311; p = 0.020 and R = 0.437; p = 0.001, respectively). The MFS cohort was divided into quartiles of LASr. MFS patients in the lowest quartile of LASr (<26%) had significantly lower values of CITP:MMP1 ratio compared to the other quartiles. CONCLUSIONS: The analysis of serum biomarkers revealed the presence of increased CCL in association with reduced LASr in the MFS cohort. Our results suggest that excessive CCL may play a role in the development of primary myocardial impairment in these patients. Future studies are needed to confirm our findings and evaluate the prognostic role of CCL markers in the MFS population.

Full-Time Cardiac Intensive Care Unit Staffing by Heart Failure Specialists and its Association with Mortality Rates.

BACKGROUND: Cardiac intensive care units (CICUs) serve medically complex patients with multiorgan dysfunction. Whether a CICU that is staffed full time by heart failure (HF) specialists is associated with decreased mortality is unclear. METHODS AND RESULTS: A retrospective review of consecutive CICU admissions from January 1, 2012, to December 31, 2016, was performed. In January 2014, the CICU changed from an open unit staffed by any cardiologist to a closed unit managed by HF specialists. Patients' baseline characteristics were determined, and a multivariate regression analysis was performed to ascertain mortality rates in the CICU. Baseline severity of illness was higher in the closed/HF specialist CICU model (P< 0.001). Death occurred in 101 of 1185 patients admitted to the CICU (8.5%) in the open-unit model and in 139 of 2163 patients (6.4%) admitted to the closed/HF specialist model (absolute risk reduction 2.1%, 95% confidence interval [CI] 0.1-4.0%; P = 0.01). The transition from an open to a closed/HF specialist model was associated with a lower overall CICU mortality rate (odds ratio [OR] 0.63; 95% CI 0.43-0.93). Prespecified interaction with a mechanical circulatory support device and unit model showed that treatment with such a device was associated with lower mortality rates in the closed/HF specialist model of a CICU (OR 0.6; 95% CI 0.18-0.78; P for interaction <0.01). CONCLUSION: Transition to a closed unit model staffed by a dedicated HF specialist is associated with lower CICU mortality rates.

A multi-institutional retrospective analysis on impact of RV acute mechanical support timing after LVAD implantation on 1-year mortality and predictors of RV acute mechanical support weaning.

BACKGROUND: There is little insight into which patients can be weaned off right ventricular (RV) acute mechanical circulatory support (AMCS) after left ventricular assist device (LVAD) implantation. We hypothesize that concomitant RV AMCS insertion instead of postoperative implantation will improve 1-year survival and increase the likelihood of RV AMCS weaning. METHODS: A multicenter retrospective database of 826 consecutive patients who received a HeartMate II or HVAD between January 2007 and December 2016 was analyzed. We identified 91 patients who had early RV AMCS on index admission. Cox proportional-hazards model was constructed to identify predictors of 1-year mortality post-RV AMCS implantation and competing risk modeling identified RV AMCS weaning predictors. RESULTS: There were 91 of 826 patients (11%) who required RV AMCS after CF-LVAD implantation with 51 (56%) receiving a concomitant RV AMCS and 40 (44%) implanted with a postoperative RV AMCS during their ICU stay; 48 (53%) patients were weaned from RV AMCS support. Concomitant RV AMCS with CF-LVAD insertion was associated with lower mortality (HR 0.45 [95% CI 0.26-0.80], p = 0.01) in multivariable model (which included age, BMI, angiotensin-converting enzyme inhibitor use, and heart transplantation as a time-varying covariate). In the multivariate competing risk analysis, a TPG < 12 (SHR 2.19 [95% CI 1.02-4.70], p = 0.04) and concomitant RV AMCS insertion (SHR 3.35 [95% CI 1.73-6.48], p < 0.001) were associated with a successful wean. CONCLUSIONS: In patients with RVF after LVAD implantation, concomitant RV AMCS insertion at the time of LVAD was associated with improved 1-year survival and increased chances of RV support weaning compared to postoperative insertion.

COVID-19 in heart transplant recipients during February-August 2020: A systematic review.

The coronavirus disease 2019 (COVID-19) pandemic represents a major concern in immunosuppressed patients such as heart transplant recipients. Therefore, we performed a systematic review to summarize the clinical features, treatment, and outcomes of heart transplant recipients with COVID-19. We searched electronic databases from inception to January 11, 2021. Thirty-nine articles (22 case reports and 17 cohorts) involving 415 patients were included. The mean age was 59.9 ± 15.7 years and 77% of patients were men. In cohort studies including outpatients and inpatients, the hospitalization rate was 77%. The most common symptoms were fever (70%) and cough (67%). Inflammatory biomarkers (C-reactive protein and procalcitonin) were above the normal range. Forty-eight percent of patients presented with severe or critical COVID-19. Hydroxychloroquine (54%), azithromycin (14%), and lopinavir/ritonavir (14%) were the most commonly used drugs. Forty-nine percent of patients discontinued the baseline regimen of antimetabolites. In contrast, 59% and 73% continued the same regimen of calcineurin inhibitors and corticosteroids, respectively. Short-term mortality among cohorts limited to inpatients was 25%. Our review suggests that heart transplant recipients with COVID-19 exhibited similar demographic and clinical features to the general population. However, the prognosis was poor in these patients.

Prediction of right heart failure after left ventricular assist implantation: external validation of the EUROMACS right-sided heart failure risk score.

AIMS: Prediction of right heart failure (RHF) after left ventricular assist device (LVAD) implant remains a challenge. The EUROMACS right-sided heart failure (EUROMACS-RHF) risk score was proposed as a prediction tool for post-LVAD RHF but lacks from large external validation. The aim of our study was to externally validate the score. METHODS AND RESULTS: From January 2007 to December 2017, 878 continuous-flow LVADs were implanted at three tertiary centres. We calculated the EUROMACS-RHF score in 662 patients with complete data. We evaluated its predictive performance for early RHF defined as either (i) need for short- or long-term right-sided circulatory support, (ii) continuous inotropic support for ≥14 days, or (iii) nitric oxide for ≥48 h post-operatively. Right heart failure occurred in 211 patients (32%). When compared with non-RHF patients, pre-operatively they had higher creatinine, bilirubin, right atrial pressure, and lower INTERMACS class (P < 0.05); length of stay and in-hospital mortality were higher. Area under the ROC curve for RHF prediction of the EUROMACS-RHF score was 0.64 [95% confidence interval (CI) 0.60-0.68]. Reclassification of patients with RHF was significantly better when applying the EUROMACS-RHF risk score on top of previous published scores. Patients in the high-risk category had significantly higher in-hospital and 2-year mortality [hazard ratio: 1.64 (95% CI 1.16-2.32) P = 0.005]. CONCLUSION: In an external cohort, the EUROMACS-RHF had limited discrimination predicting RHF. The clinical utility of this score remains to be determined.

Awake venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock.

BACKGROUND: Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) is currently one of the first-line therapies for refractory cardiogenic shock (CS), but its applicability is undermined by the high morbidity associated with its complications, especially those related to mechanical ventilation (MV). We aimed to assess the prognostic impact of keeping patients in refractory CS awake at cannulation and during the VA-ECMO run. METHODS: A 7-year database of patients given peripheral VA-ECMO support was used to conduct a propensity-score (PS)-matched analysis to balance their clinical profiles. Patients were classified as 'awake ECMO' or 'non-awake ECMO', respectively, if invasive MV was used during ≤50% or >50% of the VA-ECMO run. Primary outcomes included ventilator-associated pneumonia and ECMO-related complication rates, and secondary outcomes were 60-day and 1-year mortality. A multivariate logistic-regression analysis was used to identify whether MV at cannulation was independently associated with 60-day mortality. RESULTS: Among 231 patients included, 91 (39%) were 'awake' and 140 (61%) 'non-awake'. After PS-matching adjustment, the 'awake ECMO' group had significantly lower rates of pneumonia (35% vs. 59%, P = 0.017), tracheostomy, renal replacement therapy, and less antibiotic and sedative consumption. This strategy was also associated with reduced 60-day (20% vs. 41%, P = 0.018) and 1-year mortality rates (31% vs. 54%, P = 0.021) compared to the 'non-awake' group, respectively. Lastly, MV at ECMO cannulation was independently associated with 60-day mortality. CONCLUSION: An 'awake ECMO' management in VA-ECMO-supported CS patients is feasible, safe, and associated with improved short- and long-term outcomes.