Risk factors for cardiogenic shock in thyroid storm: a retrospective and case-series study.

Aim: Thyroid storm (TS) occurs in 10% of thyrotoxicosis patients and 1% of TS patients experience cardiogenic shock (CS), which is associated with poor prognosis. Methods: This is a single institution, retrospective study in which 56 patients with TS were evaluated. Results: BMI (p = 0.002), history of heart failure (OR 8.33 [1.91, 36.28]; p = 0.004), pro-BNP elevation (p = 0.04), chest x-ray showing interstitial edema (OR 3.33 [1.48, 7.52]; p = 0.01) and Burch-Wartofsky score (62.5 vs 40; p = 0.004) showed association with CS. CS patients had increased length of stay (16.5 vs 4 days; p = 0.01) and higher in-hospital mortality (OR 24.5 [2.90, 207.29]; p < 0.001). Conclusion: These risk factors are useful to risk stratify TS patients on admission, institute therapy in a timely manner and decrease mortality.

Pulmonary hypertension predicts higher mortality in patients admitted with severe COVID-19 infection.

Objective: Patients with underlying conditions are predicted to have worse outcomes with COVID-19. A strong association between baseline cardiovascular disease and COVID-19-related mortality has been shown by a number of studies. In the current retrospective study, we aim to identify whether patients with pulmonary hypertension have worse outcomes compared with patients without pulmonary hypertension. Methods: Data from patients of ⩾18 years of age with COVID was retrospectively collected and analyzed (n = 679). Patients who underwent transthoracic echocardiography, at the discretion of the medical team, were identified and the transthoracic echocardiography was reviewed for the presence of pulmonary hypertension. Patient health parameters and outcomes were measured and statistically analyzed. Results: Of 679 consecutive patients identified with a diagnosis of COVID-19, 57 underwent transthoracic echocardiography, 32 of which were found to have pulmonary hypertension. Patients who underwent transthoracic echocardiography had a significantly higher intensive care unit admission rate (73.7% versus 25.4%, p < 0.001) and increased presence of acute respiratory distress syndrome (63.2% versus 21.6%, p > 0.001). These patients had longer intensive care unit length of stay, longer mechanical ventilation time, longer hospital length of stay, and a significantly higher mortality rate when compared to those not undergoing transthoracic echocardiography (59.7% versus 32.3%, p < 0.001). Among patients who underwent transthoracic echocardiography, those with pulmonary hypertension had significantly higher mortality compared to those without pulmonary hypertension (80% versus 43.8%, p < 0.01). Conclusion: COVID-19 in patients with pulmonary hypertension was associated with high in-hospital mortality even when adjusted for confounding factors. A number of mechanisms have been proposed for the worse outcomes in patients with pulmonary hypertension and right ventricular dysfunction, including right ventricle overload and indirect pro-inflammatory cytokine storm. Further, large-scale studies are required to evaluate the impact of right ventricular dysfunction in COVID-19 patients and to elucidate the associated mechanisms.

Impact of acute TTE-evidenced cardiac dysfunction on in-hospital and outpatient mortality: A multicenter NYC COVID-19 registry study.

BACKGROUND: COVID-19 is associated with cardiac dysfunction. This study tested the relative prognostic role of left (LV), right and bi- (BiV) ventricular dysfunction on mortality in a large multicenter cohort of patients during and after acute COVID-19 hospitalization. METHODS/RESULTS: All hospitalized COVID-19 patients who underwent clinically indicated transthoracic echocardiography within 30 days of admission at four NYC hospitals between March 2020 and January 2021 were studied. Images were re-analyzed by a central core lab blinded to clinical data. Nine hundred patients were studied (28% Hispanic, 16% African-American), and LV, RV and BiV dysfunction were observed in 50%, 38% and 17%, respectively. Within the overall cohort, 194 patients had TTEs prior to COVID-19 diagnosis, among whom LV, RV, BiV dysfunction prevalence increased following acute infection (p<0.001). Cardiac dysfunction was linked to biomarker-evidenced myocardial injury, with higher prevalence of troponin elevation in patients with LV (14%), RV (16%) and BiV (21%) dysfunction compared to those with normal BiV function (8%, all p<0.05). During in- and out-patient follow-up, 290 patients died (32%), among whom 230 died in the hospital and 60 post-discharge. Unadjusted mortality risk was greatest among patients with BiV (41%), followed by RV (39%) and LV dysfunction (37%), compared to patients without dysfunction (27%, all p<0.01). In multivariable analysis, any RV dysfunction, but not LV dysfunction, was independently associated with increased mortality risk (p<0.01). CONCLUSIONS: LV, RV and BiV function declines during acute COVID-19 infection with each contributing to increased in- and out-patient mortality risk. RV dysfunction independently increases mortality risk.

Using Mobile Integrated Health and telehealth to support transitions of care among patients with heart failure (MIGHTy-Heart): protocol for a pragmatic randomised controlled trial.

INTRODUCTION: Nearly one-quarter of patients discharged from the hospital with heart failure (HF) are readmitted within 30 days, placing a significant burden on patients, families and health systems. The objective of the 'Using Mobile Integrated Health and Telehealth to support transitions of care among patients with Heart failure' (MIGHTy-Heart) study is to compare the effectiveness of two postdischarge interventions on healthcare utilisation, patient-reported outcomes and healthcare quality among patients with HF. METHODS AND ANALYSIS: The MIGHTy-Heart study is a pragmatic comparative effectiveness trial comparing two interventions demonstrated to improve the hospital to home transition for patients with HF: mobile integrated health (MIH) and transitions of care coordinators (TOCC). The MIH intervention bundles home visits from a community paramedic (CP) with telehealth video visits by emergency medicine physicians to support the management of acute symptoms and postdischarge care coordination. The TOCC intervention consists of follow-up phone calls from a registered nurse within 48-72 hours of discharge to assess a patient's clinical status, identify unmet clinical and social needs and reinforce patient education (eg, medication adherence and lifestyle changes). MIGHTy-Heart is enrolling and randomising (1:1) 2100 patients with HF who are discharged to home following a hospitalisation in two New York City (NY, USA) academic health systems. The coprimary study outcomes are all-cause 30-day hospital readmissions and quality of life measured with the Kansas City Cardiomyopathy Questionnaire 30 days after hospital discharge. The secondary endpoints are days at home, preventable emergency department visits, unplanned hospital admissions and patient-reported symptoms. Data sources for the study outcomes include patient surveys, electronic health records and claims submitted to Medicare and Medicaid. ETHICS AND DISSEMINATION: All participants provide written or verbal informed consent prior to randomisation in English, Spanish, French, Mandarin or Russian. Study findings are being disseminated to scientific audiences through peer-reviewed publications and presentations at national and international conferences. This study has been approved by: Biomedical Research Alliance of New York (BRANY #20-08-329-380), Weill Cornell Medicine Institutional Review Board (20-08022605) and Mt. Sinai Institutional Review Board (20-01901). TRIAL REGISTRATION NUMBER: Clinicaltrials.gov, NCT04662541.

Identify Early and Involve Everyone: Interdisciplinary Comprehensive Care Pathway Developed for Inpatient Management and Transitions of Care for Heart Failure Patients Reported Using SQUIRE 2.0 Guidelines.

Introduction Heart failure accounts for 1-2% of overall healthcare costs. While the link between re-hospitalization and mortality is unclear, care pathways that standardize inpatient management and establish outpatient follow-up improve patient outcomes and reduce morbidity. Aim To implement a comprehensive interdisciplinary care pathway for heart failure patients with the goal of optimizing inpatient management and improving transitions of care. Methods To address this clinical need, New York-Presbyterian Brooklyn Methodist Hospital (NYP-BMH) identified resources needed to optimize patient care, developed an inpatient admission order set (so-called "power plan"), and implemented a multidisciplinary clinical care pathway. The Plan-Do-Study-Act cycle addressed the implementation obstacles. Interdisciplinary rounds guided day-to-day management and addressed barriers. Our team developed a sustainable care pathway, and measured the utilization of pharmacy, nutrition, physical therapy, case management, and social work resources; outpatient appointments were made prior to discharge. We used the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines to guide our planning and evaluation of this quality improvement initiative. Results Our intervention markedly increased the number of heart failure hospitalizations that were identified on admission, and the use of pharmacy/nutrition services was greater after the intervention. The utilization of our "power plan" promoted adherence to a series of evidence-based best practices, but these measures had no significant impact on readmissions as a whole. The involvement of the case management support team increased outpatient appointments made for patients prior to discharge and aided in the transition of care from inpatient to outpatient management. Conclusion The management of heart failure patients starts in the hospital and continues in the community. Patients who are treated in a standardized dedicated care pathway have reduced morbidity and better outcomes. Identifying these patients early, involving a comprehensive team, and transitioning their care to the outpatient setting improves the quality of care in these patients.

A comparison of existing risk prediction models in patients undergoing venoarterial extracorporeal membrane oxygenation.

BACKGROUND: Patients undergoing consideration for venoarterial extracorporeal membrane oxygenation (VA-ECMO) require an immediate risk profile assessment in the setting of incomplete information. A number of survival prediction models for critically ill patients and patients undergoing elective cardiac surgery or institution of VA-ECMO support have been designed. We assess the ability of these models to predict outcomes in a cohort of patients undergoing institution of VA-ECMO for cardiogenic shock or cardiac arrest. METHODS: Fifty-one patients undergoing institution of VA-ECMO support were retrospectively analyzed. APACHE II, SOFA, SAPS II, Encourage, SAVE, and ACEF scores were calculated. Their ability to predict outcomes were assessed. RESULTS: Indications for ECMO support included postcardiotomy shock (25%), ischemic etiologies (39%), and other etiologies (36%). Pre-ECMO arrest occurred in 73% and 41% of patients underwent cannulation during arrest. Survival to discharge was 39%. Three survival prediction model scores were significantly higher in nonsurvivors to discharge than surivors; the Encourage score (25.4 vs 20; p = .04), the APACHE II score (23.6 vs 19.2; p = .05), and the ACEF score (3.1 vs 1.8; p = .03). In ROC analysis, the ACEF score demonstrated the greatest predictive ability with an AUC of 0.7. CONCLUSIONS: A variety of survival prediction model scores designed for critically ill ICU and VA-ECMO patients demonstrated modest discriminatory ability in the current cohort of patients. The ACEF score, while not designed to predict survival in critically ill patients, demonstrated the best discriminatory ability. Furthermore, it is the simplest to calculate, an advantage in the emergent setting.

Left Ventricular Outflow Tract Obstruction From Preserved Leaflet After Mitral Valve Replacement.

Left ventricular outflow tract obstruction (LVOTO) can be caused by multiple factors. One of the rare causes of LVOTO is preserved anterior mitral valve leaflet and chordal apparatus after mitral valve replacement. We describe a case of a patient with worsening chronic congestive heart failure secondary to LVOTO from systolic anterior motion of residual native anterior mitral leaflet. In this patient, LVOTO was surgically corrected by excision of anterior leaflet and chordal apparatus through the aortic root.

A Simple Scoring System to Predict Survival after Venoarterial Extracorporeal Membrane Oxygenation.

Patients undergoing consideration for venoarterial extracorporeal membrane oxygenation (VA ECMO) require an immediate risk profile assessment in the setting of incomplete or no information. A retrospective cohort study of 100 patients undergoing VA ECMO placement at three institutions was carried out. Variables strongly associated with survival to discharge were used to calculate a risk stratification score. Indications for VA ECMO support included postcardiotomy shock (24%), ischemic etiologies (33%), nonischemic cardiomyopathy (32%), and other etiologies (11%). Pre-VA ECMO arrest occurred in 69%, and 30% of patients underwent cannulation during arrest. Survival to discharge was 38%. Three variables demonstrated a strong trend toward predicting survival to discharge: lactate >10 mmol/L (p = .054), albumin <3 g/dL (p = .062), and platelet count <180 K/uL (p = .064), and these variables were included in a scoring system. The extremes of age and duration of pre-VA ECMO ventilation were associated with a dismal prognosis and were also included. These five variables were used to construct a mortality prediction score. A score of 0 was associated with 10% expected mortality, whereas a score of 4+ was associated with 100% expected mortality. Mortality increased in a stepwise fashion with increasing scores. The expected mortality closely paralleled the observed mortality. A simple scoring system composed of easily collected variables may help predict mortality. However, it is not intended to replace an experienced clinician's judgment, but to enhance it.

Convergent ablation for persistent atrial fibrillation: Single center experience.

BACKGROUND: Endocardial catheter ablation has been shown to be effective in patients with paroxysmal atrial fibrillation (AF), and significantly less effective in patients with persistent AF (PAF). Lately, there is a trend toward a hybrid approach in the treatment of PAF that may be a more durable treatment for patients with PAF. In this manuscript we report our experience with the convergent ablation procedure in a PAF cohort. METHODS: This is a single center retrospective analysis of 31 patients with PAF who underwent the convergent procedure. All patients underwent surgical epicardial ablation of the posterior left atrial through a subxiphoid approach, followed by radiofrequency endocardial ablations on the same day. Patients were followed at 6 months intervals with static electrocardiograms or implanted devices. RESULTS: Sinus rhythm was achieved intraoperatively in all patients. Recurrence was defined according to Hearlt Rhythm Society definitions. At a median follow up of 17.7 months (IQR 11-24), the recurrence of atrial tachyarrhythmia (AF and atrial flutter) by Kaplan-Meier event free survival analysis occurred in 9 (29%) patients at 1-year follow up and 15 (48%) patients at 2-year follow up with or without the use of antiarrhythmic drugs. Recurrence of AF alone occurred in 4 (13%) patients at 1-year follow up and 9 (29%) patients at 2-year follow up patients. Complication rate in perioperative period was 12.9%. CONCLUSION: Our experience showed the hybrid procedure is a relatively safe and effective option for patients with PAF. Further studies are needed to better determine its long-term outcomes.

Complete Myocardial Function Recovery with ECMO in a Woman Presenting with Cardiogenic Shock during Peripartum Period.

Peripartum cardiomyopathy is a potentially life-threatening cause of heart failure (HF) that affects women toward the end of pregnancy or in months after delivery. Treatment is similar to the treatment for HF with reduced ejection fraction (EF). Most women make full myocardial function recovery within 6 months on conventional HF therapy. In rare instances, catastrophic presentations may occur with hemodynamic instability requiring the use of mechanical support. Because of the small patient population, limited information is available regarding the recovery of myocardial function in women who received mechanical support. We present a case of a woman in her peripartum period who presented with cardiogenic shock and made complete myocardial function recovery after 4 days of extracorporeal membrane oxygenation (ECMO). Our patient's EF at the time of catastrophe was 5-10%, which improved to 60% on day 4 on ECMO.

Right atrial volume by cardiovascular magnetic resonance predicts mortality in patients with heart failure with reduced ejection fraction.

BACKGROUND: Right Atrial Volume Index (RAVI) measured by echocardiography is an independent predictor of morbidity in patients with heart failure (HF) with reduced ejection fraction (HFrEF). The aim of this study is to evaluate the predictive value of RAVI assessed by cardiac magnetic resonance (CMR) for all-cause mortality in patients with HFrEF and to assess its additive contribution to the validated Meta-Analysis Global Group in Chronic heart failure (MAGGIC) score. METHODS AND RESULTS: We identified 243 patients (mean age 60 ± 15; 33% women) with left ventricular ejection fraction (LVEF) ≤ 35% measured by CMR. Right atrial volume was calculated based on area in two- and four -chamber views using validated equation, followed by indexing to body surface area. MAGGIC score was calculated using online calculator. During mean period of 2.4 years 33 patients (14%) died. The mean RAVI was 53 ± 26 ml/m2; significantly larger in patients with than without an event (78.7±29 ml/m2 vs. 48±22 ml/m2, p<0.001). RAVI (per ml/m2) was an independent predictor of mortality [HR = 1.03 (1.01-1.04), p = 0.001]. RAVI has a greater discriminatory ability than LVEF, left atrial volume index and right ventricular ejection fraction (RVEF) (C-statistic 0.8±0.08 vs 0.55±0.1, 0.62±0.11, 0.68±0.11, respectively, all p<0.02). The addition of RAVI to the MAGGIC score significantly improves risk stratification (integrated discrimination improvement 13%, and category-free net reclassification improvement 73%, both p<0.001). CONCLUSION: RAVI by CMR is an independent predictor of mortality in patients with HFrEF. The addition of RAVI to MAGGIC score improves mortality risk stratification.

Myocardial Viability and Revascularization: Current Understanding and Future Directions.

The initial observation of functional recovery in dysfunctional myocardium following revascularization led to the introduction of the concept of hibernating myocardium. Since then, the pathophysiologic basis of hibernating myocardium has been well described. Multiple imaging modalities have been utilized to prospectively detect viable myocardium and thus predict its functional recovery following revascularization. It has been hypothesized that viability imaging will be instrumental in the selection of patients with ischemic cardiomyopathy likely to benefit from revascularization. Multiple observational studies built a large body of evidence supporting this concept. However, data from prospective studies failed to substantiate utility of viability testing. This review aims to summarize the current literature and describe the role of viability imaging in current clinical practice as well as future directions.

Worsening renal function is not associated with response to treatment in acute heart failure.

BACKGROUND: About a fourth of acute decompensated heart failure (ADHF) patients develop renal dysfunction during their admission. To date, the association of ADHF treatment with the development of worsening renal function (WRF) remains contentious. Thus, we examined the association of WRF with changes in BNP levels and with mortality. METHODS: We performed retrospective chart review of patients admitted with ADHF who had BNP, eGFR, creatinine and blood urea nitrogen (BUN) values measured both on admission and discharge. Survival analysis was conducted using Cox proportional hazards model and correlation was measured using Spearman's rank correlation test. RESULTS: 358 patients admitted for ADHF were evaluated. WRF was defined as >20% reduction in eGFR from admission to discharge and response to treatment was assessed by ΔBNP. There was a statistically significant reduction in BNP and increase in BUN during the admission. ΔBNP did not correlate with either ΔGFR or ΔBUN. Patients who developed WRF and those who did not, had a similar reduction in BNP. On univariate survival analysis, ΔBUN, but not ΔeGFR, was associated with 1-year mortality. In multivariate Cox proportional hazards model, BUN at discharge was associated with 1-year mortality (HR: 1.02, p<0.001), but ΔeGFR and ΔBUN were not associated with the primary endpoint. CONCLUSION: During ADHF treatment, ΔBNP was not associated with changes in renal function. Development of WRF during ADHF treatment was not associated with mortality. Our study suggests that development of WRF should not preclude diuresis in ADHF patients in the absence of volume depletion.

Recurrent low-level troponin I elevation is a worse prognostic indicator than occasional injury pattern in patients hospitalized with heart failure.

BACKGROUND: Elevated troponin at baseline is associated with higher mortality in heart failure (HF) patients, but the prognostic role of recurrently elevated troponin is not well described. METHODS AND RESULTS: We performed chart reviews of 196 HF patients without acute coronary syndrome, with at least three Troponin I (TnI) measurements on different admissions. For the analyses, three sets of TnI values closest to baseline, one year and two years were selected for each patient. Based on the three sets of TnI, the lowest value of TnI (minimum), the highest value of TnI (maximum), median value of TnI and delta TnI (3rd TnI-baseline TnI) were derived for each patient. The study population of 196 patients had 632 person-year follow-up, consisted predominantly of elderly (68 ± 10 years) male patients (99%) with mean ejection fraction of 26 ± 13%. Using multivariate Cox proportional hazards model only minimum TnI, but not the maximum, median or delta of TnI values, was significantly associated with mortality (HR: 13.7, 95% CI: 3.7 to 50.8, p<0.001). As a categorical variable, minimum TnI value of >0.04ng/ml was also independently associated with mortality (p=0.01, HR=1.6, 95% CI: 1.1 to 2.3). CONCLUSIONS: In HF patients without acute coronary syndrome, the persistence of TnI elevation, even at low levels, is associated with a worse survival than sporadic TnI elevations of higher magnitude or any single elevation in TnI; and a recurrent elevation of TnI >0.04ng/ml portends a poor prognosis.

Echocardiographic changes during treatment of acute decompensated heart failure: insights from the ESCAPE trial.

BACKGROUND: Long-term heart failure (HF) treatment has been shown to result in reverse chamber remodeling. However, it is unknown whether sizes of cardiac chambers acutely change during HF therapy and whether these changes are associated with favorable clinical outcomes. METHODS AND RESULTS: Using the Evaluation Study of Congestive Heart Failure and Pulsmonary Artery Catheterization Effectiveness (ESCAPE) trial database, echocardiographic parameters at baseline and discharge, changes from baseline to discharge, and their association with the combined endpoint of death or HF rehospitalization (HFH) at 6 months were evaluated in patients admitted with acute decompensated HF (ADHF). Also, the correlation between changes in invasive hemodynamic parameters compared with changes in echocardiographic parameters was analyzed. During the treatment of ADHF, right atrium, right ventricle, and inferior vena cava (IVC) sizes decreased acutely. Mitral regurgitation severity and mitral inflow parameters also improved significantly. However, the majority of acute changes in echocardiographic parameters did not have an impact on clinical outcome, except for the reduction in left ventricular (LV) end-diastolic and end-systolic volumes, which was associated with a reduction in the combined outcome of HFH or death. The change in invasive hemodynamics that best correlated with change in echocardiographic parameters was change in pulmonary capillary wedge pressure with change in IVC diameter and IVC collapsibility. CONCLUSIONS: This is the first study to identify the echocardiographic parameters that change during the treatment of ADHF and the echocardiographic parameters that most reliably correlate with invasive hemodynamic changes. Most changes in echocardiographic parameters were not associated with clinical outcomes, except for the reduction in LV volume, which was associated with a reduction in HFH or death.

Impact of noncardiac comorbidities on morbidity and mortality in a predominantly male population with heart failure and preserved versus reduced ejection fraction.

OBJECTIVES: The aim of this study was to evaluate the prevalence and prognostic impacts of noncardiac comorbidities in patients with heart failure (HF) with preserved ejection fraction (HFpEF) compared with those with HF with reduced ejection fraction (HFrEF). BACKGROUND: There is a paucity of information on the comparative prognostic significance of comorbidities between patients with HFpEF and those with HFrEF. METHODS: In a national ambulatory cohort of veterans with HF, the comorbidity burden of 15 noncardiac comorbidities and the impacts of these comorbidities on hospitalization and mortality were compared between patients with HFpEF and those with HFrEF. RESULTS: The cohort consisted of 2,843 patients with HFpEF and 6,599 with HFrEF with 2-year follow-up. Compared with patients with HFrEF, those with HFpEF were older and had higher prevalence of chronic obstructive pulmonary disease, diabetes, hypertension, psychiatric disorders, anemia, obesity, peptic ulcer disease, and cancer but a lower prevalence of chronic kidney disease. Patients with HFpEF had lower HF hospitalization, higher non-HF hospitalization, and similar overall hospitalization compared with those with HFrEF (p < 0.001, p < 0.001, and p = 0.19, respectively). An Increasing number of noncardiac comorbidities was associated with a higher risk for all-cause admissions (p < 0.001). Comorbidities had similar impacts on mortality in patients with HFpEF compared with those with HFrEF, except for chronic obstructive pulmonary disease, which was associated with a higher hazard (1.62 [95% confidence interval: 1.36 to 1.92] vs. 1.23 [95% confidence interval: 1.11 to 1.37], respectively, p = 0.01 for interaction) in patients with HFpEF. CONCLUSIONS: There is a higher noncardiac comorbidity burden associated with higher non-HF hospitalizations in patients with HFpEF compared with those with HFrEF. However, individually, most comorbidities have similar impacts on mortality in both groups. Aggressive management of comorbidities may have an overall greater prognostic impact in HFpEF compared to HFrEF.