Right atrial pressure torsades de pointes.

A 39-year-old man with non-ischemic cardiomyopathy presented for routine right heart catheterization.

Ascites and Edema After Bicaval Orthotopic Heart Transplant.

IVC stenosis is a rare complication of bicaval orthotopic heart transplant. IVC stenosis can occur at either the cavo-atrial anastomosis, or the caval cannulation site, with presentations ranging from acute shock early post transplant to a more indolent course. Causes include extensive hemostatic suturing, fibrous contraction, and donor-recipient size mismatch. Treatment strategies include percutaneous balloon angioplasty, stenting, and surgical revision. Evaluating for IVC stenosis is recommended for unexplained lower-extremity edema, new-onset ascites, or liver abnormalities after bicaval heart transplant.

A novel phonetic approach to continuous flow left ventricular assist device auscultation.

BACKGROUND: The dominant sound generated by continuous flow left ventricular assist devices (cf-LVADs) has generically been referred to as a "hum". This term, however, implies that despite distinct engineering designs, all cf-LVADs generate the same quality of sound. Furthermore, no structured method for auscultation of cf-LVADs exists. We hereby report a novel and simple phonetic approach to device auscultation, the aims of which are to improve recognition, understanding, and teaching of sound produced by normally functioning cf-LVADs. We sought to evaluate whether clinically relevant pump or person related events can produce changes in the expected audio fingerprint of a particular cf-LVAD, and whether these changes in sound can be identified by auscultation and translated phonetically. METHODS: Sound recordings were made on 7 people implanted with one of 3 U.S. Food and Drug Administration (FDA) approved cf-LVADs. Of the 7, 3 were considered to have normal device function and stable condition. The remaining 4 people had a clinically relevant pump or person related event. Recordings were made with a stethoscope attachment that allows digital recording of sound and provides a real time phonocardiogram. RESULTS: The main findings were the following: 1.) each cf-LVAD generates a unique audio fingerprint 2.) the audio fingerprint can be phonetically translated in a simple manner. 3.) pump or patient related events result in changes in device sound, that can be appreciated phonetically. CONCLUSIONS: Phonetics offer a novel and easily reproducible method for evaluation and teaching normal cf-LVAD sounds by auscultation. Additionally, clinically relevant pump or person related events can produce changes in the expected audio fingerprint of a particular cf-LVAD. These changes in sound can be identified by auscultation and translated phonetically. Auscultation is an important component of the physical examination of people supported with cf-LVADs.

Invasive Hemodynamic Red Flags to Left Ventricular Assist Device Implantation.

Reliable identification of patients at high risk for right ventricular failure is very important. We identify 4 parameters as hemodynamic red flags to left ventricular assist device implantation.

Heterozygous Cystic Fibrosis Transmembrane Regulator Gene Missense Variants Are Associated With Worse Cardiac Function in Patients With Duchenne Muscular Dystrophy.

Background Duchenne muscular dystrophy (DMD) is a neuromuscular disorder caused by mutations within the dystrophin gene. DMD is characterized by progressive skeletal muscle degeneration and atrophy and progressive cardiomyopathy. It has been observed the severity of cardiomyopathy varies in patients with DMD. Methods and Results A cohort of male patients with DMD and female DMD carriers underwent whole exome sequencing. Potential risk factor variants were identified according to their functional annotations and frequencies. Cardiac function of 15 male patients with DMD was assessed by cardiac magnetic resonance imaging, and various cardiac magnetic resonance imaging parameters and circulating biomarkers were compared between genotype groups. Five subjects carrying potential risk factor variants in the cystic fibrosis transmembrane regulator gene demonstrated lower left ventricular ejection fraction, larger left ventricular end-diastolic volume, and higher NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels compared with 10 subjects who did not carry the potential risk factor variants (P=0.023, 0.019 and 0.028, respectively). Conclusions This study revealed heterozygous cystic fibrosis transmembrane regulator gene missense variants were associated with worse cardiac function in patients with DMD. The cystic fibrosis transmembrane regulator gene may serve as a genetic modifier that accounts for more severe cardiomyopathy in patients with DMD, who would require more aggressive management of the cardiomyopathy.

Saved by the VAC: Minimally Invasive Removal of a Surely Fatal Right Heart Thrombus in a Patient with Advanced Heart Failure.

Intracardiac thrombi are associated with an increased morbidity and mortality due to their unpredictability and embolic potential. Right heart thrombus is infrequently encountered in clinical practice outside the scenario of acute pulmonary embolism with hemodynamic compromise, and even more uncommon is the presence of a massive right heart thrombus. Embolic potential is high, and historically, management has revolved around open surgical removal or systemic thrombolysis. We hereby present a case of a massive right heart thrombus in a high surgical risk patient, which was successfully removed using a percutaneous aspiration device.

Impact of induction immunosuppression on patient survival in heart transplant recipients treated with tacrolimus and mycophenolic acid in the current allocation era.

BACKGROUND: The practice of induction therapy with either rabbit anti-thymocyte globulin (r-ATG) or interleukin-2 receptor antagonists (IL-2RA) is common among heart transplant recipients. However, its benefits in the setting of contemporary maintenance immunosuppression with tacrolimus/mycophenolic acid (TAC/MPA) are unknown. METHODS: We compared post-transplant mortality among three induction therapy strategies (r-ATG vs IL2-RA vs no induction) in a retrospective cohort analysis of heart transplant recipients maintained on TAC/MPA in the Organ Procurement Transplant Network (OPTN) database between the years 2006 and 2015. We used a multivariable model adjusting for clinically important co-morbidities, and a propensity score analysis using the inverse probability weighted (IPW) method in the final analysis. RESULTS: In multivariable IPW analysis, r-ATG (HR = 1.23; 95% CI = 1.05-1.46, P = 0.01) remained significantly associated with a higher mortality. There was a trend toward having a higher mortality in the IL2-RA (HR = 1.11; 95% CI = 1.00-1.24, P = 0.06) group. Subgroup analyses failed to show a patient survival benefit in using either r-ATG or IL2-RA among any of the subgroups analyzed. CONCLUSION: In this contemporary cohort of heart transplant recipients receiving TAC/MPA, neither r-ATG nor IL2-RA were associated with a survival benefit. On the contrary, adjusted analyses showed a significantly higher mortality in the r-ATG group and a trend toward higher mortality in the IL2-RA group. While caution is needed in interpreting treatment effects in an observational cohort, these data call into question the benefit of induction therapy as a common practice and highlight the need for more studies.

Delayed febrile response with bloodstream infections in patients with continuous-flow left ventricular assist devices.

Bloodstream infections (BSIs) are common in patients with continuous-flow left ventricular assist devices (CF-LVADs). Whether CF-LVADs modulate the febrile response to BSIs is unknown. We retrospectively compared the febrile response to BSIs in patients with heart failure (HF) with CF-LVADs versus a control population of patients with HF receiving inotropic infusions. BSIs were adjudicated using the Centers for Disease Control and Prevention and the National Healthcare Safety Network criteria. Febrile status (temperature ≥38°C, 100.4 °F), temperature at presentation with BSI, and the highest temperature within 72 hours (Tmax) were collected. We observed 59 BSIs in LVAD patients and 45 BSIs in controls. LVAD patients were more likely to be afebrile and to have a lower temperature at presentation than control (88% vs 58%, p=0.002, and 37°C ±0.7 vs 37.7°C ±1.0, p=0.0009, respectively). By 72 hours, the difference in afebrile status diminished (53% vs 44%, p=0.42), and the Tmax was similar between the LVAD and control groups (37.9°C±0.9 vs 38.2°C±0.8, respectively, p=0.10). In conclusion, at presentation with a BSI, the vast majority of CF-LVAD patients were afebrile, an event which occurred at a higher frequency when compared with patients with advanced HF on chronic inotropes via an indwelling venous catheter. These data alert clinicians to have a very low threshold to obtain blood cultures in CF-LVAD patients even in the absence of fever. Further study is needed to determine whether a delayed or diminished febrile response represents another pathophysiological consequence of CF-LVADs.

Induction regimen and survival in simultaneous heart-kidney transplant recipients.

BACKGROUND: Induction therapy in simultaneous heart-kidney transplantation (SHKT) is not well studied in the setting of contemporary maintenance immunosuppression consisting of tacrolimus (TAC), mycophenolic acid (MPA), and prednisone (PRED). METHODS: We analyzed the Organ Procurement and Transplant Network registry from January 1, 2000, to March 3, 2015, for recipients of SHKT (N = 623) maintained on TAC/MPA/PRED at hospital discharge. The study cohort was further stratified into 3 groups by induction choice: induction (n = 232), rabbit anti-thymoglobulin (r-ATG; n = 204), and interleukin-2 receptor-α (n = 187) antagonists. Survival rates were estimated using the Kaplan-Meier estimator. Multivariable inverse probability weighted Cox proportional hazard regression models were used to assess hazard ratios associated with post-transplant mortality as the primary outcome. The study cohort was censored on March 4, 2016, to allow at least 1-year of follow-up. RESULTS: During the study period, the number of SHKTs increased nearly 5-fold. The Kaplan-Meier survival curve showed superior outcomes with r-ATG compared with no induction or interleukin-2 receptor-α induction. Compared with the no-induction group, an inverse probability weighted Cox proportional hazard model showed no independent association of induction therapy with the primary outcome. In sub-group analysis, r-ATG appeared to lower mortality in sensitized patients with panel reactive antibody of 10% or higher (hazard ratio, 0.19; 95% confidence interval, 0.05-0.71). CONCLUSION: r-ATG may provide a survival benefit in SHKT, especially in sensitized patients maintained on TAC/MPA/PRED at hospital discharge.

Predictors of Death in Adults With Duchenne Muscular Dystrophy-Associated Cardiomyopathy.

BACKGROUND: Duchenne muscular dystrophy (DMD) is frequently complicated by development of a cardiomyopathy. Despite significant medical advances provided to DMD patients over the past 2 decades, there remains a group of DMD patients who die prematurely. The current study sought to identify a set of prognostic factors that portend a worse outcome among adult DMD patients. METHODS AND RESULTS: A retrospective cohort of 43 consecutive patients was followed in the adult UT Southwestern Neuromuscular Cardiomyopathy Clinic. Clinical data were abstracted from the electronic medical record to generate baseline characteristics. The population was stratified by survival to time of analysis and compared with characteristics associated with death. The DMD population was in the early 20s, with median follow-up times over 2 years. All the patients had developed a cardiomyopathy, with the majority of the patients on angiotensin-converting enzyme inhibitors (86%) and steroids (56%), but few other guideline-directed heart failure medications. Comparison between the nonsurviving and surviving cohorts found several poor prognostic factors, including lower body mass index (17.3 [14.8-19.3] versus 25.8 [20.8-29.1] kg/m2, P<0.01), alanine aminotransferase levels (26 [18-42] versus 53 [37-81] units/L, P=0.001), maximum inspiratory pressures (13 [0-30] versus 33 [25-40] cmH2O, P=0.03), and elevated cardiac biomarkers (N-terminal pro-brain natriuretic peptide: 288 [72-1632] versus 35 [21-135] pg/mL, P=0.03]. CONCLUSIONS: The findings demonstrate a DMD population with a high burden of cardiomyopathy. The nonsurviving cohort was comparatively underweight, and had worse respiratory profiles and elevated cardiac biomarkers. Collectively, these factors highlight a high-risk cardiovascular population with a worse prognosis.

Bendopnea and risk of adverse clinical outcomes in ambulatory patients with systolic heart failure.

BACKGROUND: Recently, the symptom of bendopnea, that is, shortness of breath when bending forwards such as when putting on shoes, has been described in heart failure patients and found to be associated with higher ventricular filling pressures, particularly in the setting of low cardiac index. However, it is not known whether bendopnea is associated with clinical outcomes. METHODS: In a prospective convenience sample of 179 patients followed in our heart failure disease management clinic, we determined the presence of bendopnea at the time of enrollment and ascertained clinical outcomes through 1 year of follow-up. We performed univariate and stepwise multivariable modeling to test the association of bendopnea with clinical outcomes. RESULTS: Bendopnea was present in 32 of 179 (18%) subjects. At 1 year, those with versus without bendopnea were at increased risk of the composite endpoint of death, heart failure admission, inotrope initiation, left ventricular assist device implantation, or cardiac transplantation in univariate (hazard ratio [HR] 1.9, P < .05) but not multivariable (HR 1.9, P = .11) analysis. Bendopnea was more strongly associated with short-term outcomes including heart failure admission at 3 months in both univariate (HR 3.1, P < .004) and multivariable (HR 2.5, P = .04) analysis. CONCLUSIONS: Bendopnea was associated with an increased risk of adverse outcomes in ambulatory patients with heart failure, particularly heart failure admission at 3 months.

Real-world lessons from the implementation of a depression screening protocol in acute myocardial infarction patients: implications for the American Heart Association depression screening advisory.

BACKGROUND: The American Heart Association (AHA) statement has recommended routine screening for depression in coronary artery disease with a 2-stage implementation of the Patient Health Questionnaire (PHQ). Because there is little evidence on feasibility, accuracy, and impact of such a program on depression recognition in coronary patients, the AHA recommendation has met substantial debate and criticism. METHODS AND RESULTS: Before the AHA statement was released, the Mid America Heart and Vascular Institute (MAHVI) had implemented a depression screening protocol for patients with acute myocardial infarction that was virtually identical to the AHA recommendations. To (1) evaluate this MAHVI quality improvement initiative, (2) compare MAHVI depression recognition rates with those of other hospitals, and (3) examine health care providers' implementation feedback, we compared the results of the MAHVI screening program with data from a parallel prospective acute myocardial infarction registry and interviewed MAHVI providers. Depressive symptoms (PHQ-2, PHQ-9) were assessed among 503 MAHVI acute myocardial infarction patients and compared with concurrent depression assessments among 3533 patients at 23 US centers without a screening protocol. A qualitative summary of providers' suggestions for improvement was also generated. A total of 135 (26.8%) eligible MAHVI patients did not get screened. Among screened patients, 90.9% depressed (PHQ-9 ≥10) patients were recognized. The agreement between the screening and registry data using the full PHQ-9 was 61.5% for positive cases (PHQ-9 ≥10) but only 35.6% for the PHQ-2 alone. Although MAHVI had a slightly higher overall depression recognition rate (38.3%) than other centers not using a depression screening protocol (31.5%), the difference was not statistically significant (P=0.31). Staff feedback suggested that a single-stage screening protocol with continuous feedback could improve compliance. CONCLUSIONS: In this early effort to implement a depression screening protocol, a large proportion of patients did not get screened, and only a modest impact on depression recognition rates was realized. Simplifying the protocol by using the PHQ-9 alone and providing more support and feedback may improve the rates of depression detection and treatment.

Acute coronary syndrome patients with depression have low blood cell membrane omega-3 fatty acid levels.

OBJECTIVE: To determine the extent to which levels of membrane eicosapentaenoic (EPA)+docosahexaenoic acids (DHA) (the omega-3 index) were associated with depression in patients with acute coronary syndrome (ACS). Depression is associated with worse cardiovascular (CV) outcomes in patients with ACS. Reduced levels of blood cell membrane omega-3 (n-3) fatty acids (FAs), an emerging risk factor for both CV disease and depression, may help to explain the link between depression and adverse CV outcomes. METHODS: We measured membrane FA composition in 759 patients with confirmed ACS. The analysis included not only EPA and DHA but also the n-6 FAs linoleic and arachidonic acids (LA and AA). Depressive symptoms were measured with the Patient Health Questionnaire-9 (PHQ). Multivariable linear regression was used to adjust for demographic and clinical characteristics. RESULTS: There was a significant inverse relationship between the n-3 index and depressive symptoms (PHQ) in the fully adjusted model (p = .034). For every 4.54% point rise in the n-3 index, there was a 1-point decline in depressive symptoms. In contrast to the n-3 FAs, membrane levels of the n-6 FAs LA and AA were not different between depressed and nondepressed ACS patients. CONCLUSION: We found an inverse relationship between the n-3 index and the prevalence of depressive symptoms in patients with ACS. Therefore, this study supports the hypothesis that reduced n-3 FA tissue levels are a common and potentially modifiable link between depression and adverse CV outcomes.

The prevalence of unrecognized depression in patients with acute coronary syndrome.

BACKGROUND: Depression in patients with acute coronary syndrome (ACS) is common and independently prognostic of a higher mortality and worse health status. Despite great attention to its prevalence and prognostic import, little is known about how often hospitalized patients with ACS who have significant depressive symptoms are recognized while receiving routine cardiovascular care. METHODS: We performed a cross-sectional study of 1181 consecutive patients with confirmed ACS. Detailed reviews of hospital records were performed for the documentation that depressive symptoms were recognized. Multivariable regression analysis was used to identify factors associated with unrecognized depressive symptoms. RESULTS: The prevalence of moderate/severe depressive symptoms was 17.6%. Only 24.5% had documentation that their depressive symptoms were recognized. In multivariable regression analysis, characteristics associated with unrecognized depressive symptoms were race (minorities vs whites; odds ratio [OR] = 6.73, 95% confidence interval [CI] 2.62-19.33), ejection fraction (EF < 0.40 vs EF > or = 0.40; OR = 3.45, 95% CI 1.06-11.23), and education level (no college vs some college; OR = 2.77, 95% CI 1.38-5.69). CONCLUSIONS: Despite its prognostic importance and prevalence, moderate to severe depressive symptoms are poorly recognized in hospitalized patients with ACS. Better interventions are warranted to increase the recognition and improve the management of depressive symptoms in patients with ACS.