Right Ventricular Assist Device Placement During Left Ventricular Assist Device Implantation Is Associated With Improved Survival.

Right ventricular failure (RVF) is a significant cause of mortality in patients undergoing left ventricular assist device (LVAD) implantation. Although right ventricular assist devices (RVADs) can treat RVF in the perioperative LVAD period, liberal employment before RVF is not well established. We therefore compared the survival outcomes between proactive RVAD placement at the time of LVAD implantation with a bailout strategy in patients with RVF. Retrospectively, 75 adult patients who underwent durable LVAD implantation at our institution and had an RVAD placed proactively before LVAD implantation or as a bailout strategy postoperatively due to hemodynamically unstable RVF were evaluated. Patients treated with a proactive RVAD strategy had lower Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) and a higher proportion of these required temporary mechanical circulatory support (MCS) preoperatively. Preoperative hemodynamic profiling showed a low pulmonary artery pulsatility index (PAPi) score of 1.8 ± 1.4 and 1.6 ± 0.94 ( p = 0.42) in the bailout RVAD and proactive RVAD groups, respectively. Survival at 3, 6, and 12 months post-LVAD implantation was statistically significantly higher in patients who received a proactive RVAD. Thus, proactive RVAD implantation is associated with short- and medium-term survival benefits compared to a bailout strategy in RVF patients undergoing LVAD placement.

Peak troponin predicts successful weaning from VA ECMO in patients with acute myocardial infarction complicated by cardiogenic shock.

BACKGROUND: In patients treated for refractory cardiogenic shock (RCS) following acute myocardial infarction (AMI), predicting successful weaning from veno-arterial extracorporeal membrane oxygenation (VA ECMO) has important implications for decision-making and prognosis. METHODS: We performed a retrospective review of adult VA ECMO patients with RCS complicating AMI at our institution from 2010 to 2019. We evaluated use of peak troponin I as a predictor of successful decannulation. RESULTS: Sixty-two patients were analyzed; mean age 61.1 ± 9.8 years, 73% males, 62% presented with STEMI. Forty-five patients were successfully weaned (group I). Seventeen patients did not wean (group II); seven patients received a durable LVAD, 10 died. Patients from group I had significantly lower peak troponin I (89 vs 434 ng/mL, p = 0.0001). Receiver operating characteristic curves showed a peak troponin I cutoff of 400 ng/mL correctly classified patients by weaning status 90% of the time, with associated sensitivity of 71% and specificity of 98%. With each 50 ng/mL increase in troponin I, the likelihood of weaning decreased by 33%. CONCLUSIONS: Peak troponin I above 400 ng/mL may be helpful in predicting unsuccessful weaning from VA ECMO support for refractory cardiogenic shock following myocardial infarction and facilitate triage decisions regarding need for advanced therapies.

Survivors of veno-arterial membrane oxygenation have good long-term quality of life.

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is used for the management of acute cardiogenic shock with improving short term survival. However, the long-term quality of life (QOL) of this patient population is not well characterized. We prospectively evaluated the QOL of adult patients who survived VA ECMO support for cardiogenic shock at our institution between October 2011 and January 2018 with the Minnesota Living with Heart Failure Questionnaire (MLWHFQ). We surveyed survivors at 3, 6, and 9 months after discharge, and annually for up to 5 years thereafter. A total of 64 patients were evaluated: mean age 54 ± 13 years, 73% male. There were 178 total surveys completed. MLWHFQ total scores significantly improved over time and this pattern was sustained (51.7 ± 25.3 at 3 months, vs 37.7 ± 23.6 at 6 months, vs 25.4 ± 21.3 at ⩾9 months (p < 0.01, p-trend < 0.01)). Most patients supported with VA ECMO for cardiogenic shock who survive to discharge demonstrate excellent quality of life, 6 months since index hospitalization, which is maintained over subsequent years.

Device monitoring strategies in acute heart failure syndromes.

Acute heart failure syndromes (AHFS) represent the most common discharge diagnoses in adults over age 65 and translate into dramatically increased heart failure-associated morbidity and mortality. Conventional approaches to the early detection of pulmonary and systemic congestion have been shown to be of limited sensitivity. Despite their proven efficacy, disease management and structured telephone support programs have failed to achieve widespread use in part due to their resource intensiveness and reliance upon motivated patients. While once thought to hold great promise, results from recent prospective studies on telemonitoring strategies have proven disappointing. Implantable devices with their capacity to monitor electrophysiologic and hemodynamic parameters over long periods of time and with minimal reliance on patient participation may provide solutions to some of these problems. Conventional electrophysiologic parameters and intrathoracic impedance data are currently available in the growing population of heart failure patients with equipped devices. A variety of implantable hemodynamic monitors are currently under investigation. How best to integrate these devices into a systematic approach to the management of patients before, during, and after AHFS is yet to be established.

Multidisciplinary shock team is associated with improved outcomes in patients undergoing ECPR.

OBJECTIVES: Veno-arterial extracorporeal membrane oxygenation (VA ECMO) has been increasingly used in cardiopulmonary resuscitation (ECPR) in select patients. Few centers have published their experience or outcomes with ECPR. The aim of our study was to evaluate outcomes of adult patients in cardiac arrest placed on VA ECMO in the catheterization laboratory. METHODS: We performed a retrospective analysis of adult patients in refractory cardiac arrest who underwent ECPR at the Minneapolis Heart Institute (MHI) at Abbott Northwestern Hospital from January 2012 to December 2017. Relevant data were obtained from electronic medical records, including arrest to ECMO flow time, total ECMO support time, and outcomes. RESULTS: Twenty-six adult patients underwent ECPR at the study site during the defined time period. Seven patients (27%) sustained cardiac arrest out of hospital, 19 patients arrested in-hospital with eight of those occurring in the catheterization laboratory. Seventeen (65%) patients had initial rhythm of ventricular fibrillation or tachycardia (VF/VT). All patients underwent mechanical CPR with LUCAS device. Overall 30 day and 6 month survival was 69%. Median time from arrest to ECMO flow was 46 mins (21,68) vs 61 mins (36,71) in survivors and non-survivors, respectively. Sixteen of 18 survivors discharged with a CPC score of 1 or 2. CONCLUSIONS: We demonstrate that adult patients in cardiac arrest initiated on VA ECMO in the cardiac catheterization laboratory and cared for by a multidisciplinary shock team in the critical care unit have superior long-term survival and functionally favorable neurologic recovery when compared to current literature.

Clinical outcomes associated with sedation and analgesia in patients supported with venoarterial extracorporeal membrane oxygenation.

Sedatives and analgesics are frequently used in critically ill adult patients requiring mechanical ventilation in the intensive care unit, but optimal agent selection and dosing in patients supported with venoarterial extracorporeal membrane oxygenation remain poorly defined. This retrospective study evaluated whether sedative and analgesic agent selection and dosing had any impact on clinical outcomes after venoarterial extracorporeal membrane oxygenation decannulation. The primary endpoint of our study was the incidence of delirium within 48 h after venoarterial extracorporeal membrane oxygenation decannulation in patients who received an empiric ⩾50% sedation reduction of benzodiazepines (N = 22, group 2) compared to those who did not (N = 10, group 1) and those who required no sedatives within 24 h prior to venoarterial extracorporeal membrane oxygenation decannulation (N = 21, group 3). Secondary endpoints included time to extubation after decannulation, need for tracheostomy after decannulation, intensive care unit length of stay after decannulation, total hospital length of stay, and in-hospital mortality. Delirium within 48 h after decannulation was observed in 47% of all patients and did not differ between the three groups (50% vs 50% vs 43%, p = 0.9). No differences were observed in the secondary endpoints; though there was a trend toward shorter duration of mechanical ventilation and intensive care unit length of stay in patients who received an empiric ⩾50% sedation reduction. Our study suggests that we may need more than a 50% reduction in sedation but prospective studies with a larger sample size are warranted to evaluate how sedative/analgesic selection and dosing affect important clinical outcomes.

Percutaneous Venoarterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock Is Associated with Improved Short- and Long-Term Survival.

Mortality due to refractory cardiogenic shock (RCS) exceeds 50%. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has become an accepted therapy for RCS. The aim of our study was to evaluate outcomes of patients with RCS treated with percutaneous VA-ECMO (pVA-ECMO). Retrospective review of patients supported with VA-ECMO at our institution in 2012-2013. Clinical characteristics, bleeding, vascular complications, and outcomes including survival were assessed. A total of 37 patients were supported with VA-ECMO for RCS. The majority of VA-ECMO (76%) was placed in the catheterization laboratory. Nearly half (49%) of the patients presented with acute myocardial infarction. Seven patients (19%) underwent insertion of pVA-ECMO in the setting of cardiopulmonary resuscitation with mechanical chest compression device. Median duration of support was 5 days. Index hospitalization, 30-day, and 1-year survival were 65%, 65%, and 57%, respectively. Survival rate for discharged patients was 87.5% with a median follow-up of 450 days. Refractory cardiogenic shock supported with pVA-ECMO is associated with an improved survival in patients with a traditionally poor prognosis.

Radiation dose and image quality of 70 kVp functional cardiovascular computed tomography imaging in congenital heart disease.

BACKGROUND: The use of cardiac computed tomography (CT) for quantification of ventricular function is limited by relatively high radiation dose. OBJECTIVES: The goal of this study was to describe the radiation exposure and image quality of 70 kVp functional cardiac CT in patients with congenital heart disease (CHD). METHODS: A retrospective review of 70 kVp ECG gated functional CT scans using tube current modulation was performed in CHD patients at a single institution. Quantitative and qualitative (assessed by myocardial segment, 1-4; 1 = optimal) image quality was determined. Per segment image quality was compared between thin (1.5 mm) and thick (8 mm) reconstructions and by patient age and size. Scan DLP was used to estimate radiation dose. RESULTS: 72 scans were performed during the time of review (7/2013-6/2015). Median patient age was 19.5 years (8.0, 27.1) and BMI was 20.1 (16.6, 24.5) kg/m(2). Median functional scan DLP was 78.8 (45.5, 98) and unadjusted and adjusted procedural mSv were 1.10 (0.64, 1.37) and 1.13 (0.90, 1.37). Image quality of 1 was achieved in all myocardial segments in >75% of scans. Patients with a weight ≥75 kg were more likely to have a scan achieve optimal image when using thick reconstructions compared to thin (81.3% vs. 43.8%; p = 0.028). CONCLUSIONS: Imaging of ventricular function with 70 kVp in CHD patients can be done with low radiation doses and provides diagnostic image quality, particularly for patients <75 kg. In larger patients, thicker slice reconstruction improved image quality.

Elevated Soluble Fms-Like Tyrosine Kinase-1 and Placental-Like Growth Factor Levels Are Associated With Development and Mortality Risk in Heart Failure.

BACKGROUND: Vascular endothelial dysfunction may play an important role in the progression of heart failure (HF). We hypothesize that elevated levels of vascular markers, placental-like growth factor, and soluble Fms-like tyrosine kinase-1 (sFlt-1) are associated with adverse outcomes in patients with HF. We also assessed possible triggers of sFlt-1 elevation in animal HF models. METHODS AND RESULTS: We measured plasma placental-like growth factor and sFlt-1 in 791 HF patients undergoing elective coronary angiogram. Median (interquartile range) placental-like growth factor and sFlt-1 levels were 24 (20-29) and 382 (277-953) pg/mL, respectively. After 5 years of follow-up, and after using receiver operator characteristic curves to determine optimal cutoffs, high levels of sFlt-1 (≥ 280 pg/mL; adjusted hazard ratio, 1.47; 95% confidence interval, 1.03-2.09; P=0.035) but not placental-like growth factor (≥ 25 pg/mL; adjusted hazard ratio, 1.26; 95% confidence interval, 0.94-1.71, P=0.12) were associated with adverse cardiovascular outcomes. In addition, significant elevation of sFlt-1 levels was observed in left anterior descending artery ligation and transverse aortic constriction HF mouse models after 4 and 8 weeks of follow-up, suggesting vascular stress and ischemia as triggers for sFlt-1 elevation in HF. CONCLUSIONS: Circulating sFlt-1 is generated as a result of myocardial injury and subsequent HF development. Elevated levels of sFlt-1 are associated with adverse outcomes in stable patients with HF.

Phenylene-Bridged Cyclic Siloxanes as Precursors to Nonshrinking Sol-Gel Systems and Their Use as Encapsulants.

A new class of thermally robust sol-gel polymers have been prepared from the disilaoxacyclopentane derivative 1 by ring-opening polymerization to form nonshrinking polysiloxanes. This reaction, which does not need solvent or water, can be used for, amongst other things, the encapsulation of an electronic microchip.

The Changing Role for Endomyocardial Biopsy in the Diagnosis of Giant-Cell Myocarditis.

Endomyocardial biopsy (EMB) is central to the diagnosis of giant-cell myocarditis (GCM) and planning further management. There is, however, no guideline-directed recommendation on re-biopsy or left ventricular EMB in a suspected case of acute, fulminant myocarditis following an indeterminate first biopsy. This manuscript illustrates, with a case, the changing role for EMB in the current era in the diagnosis of GCM.

Cardiac contractility modulation therapy in advanced systolic heart failure.

Cardiac contractility modulation (CCM) is the application of nonexcitatory electrical signals to the myocardium, during the absolute refractory period of the action potential, to elicit a positive inotropic effect without increasing myocardial oxygen consumption. These effects are independent of QRS duration; consequently, CCM device therapy might benefit symptomatic patients with reduced left ventricular ejection fraction who are not candidates for cardiac resynchronization therapy. Preclinical studies have demonstrated a rapid positive inotropic effect of CCM, which seems to be mediated by modulation of cardiomyocyte Ca(2+) fluxes and alterations in the phosphorylation of cardiac phospholamban. In vivo translational and clinical studies that utilized double biphasic voltage pulses to the right ventricular aspect of the interventricular septum have demonstrated positive global effects on cardiac reverse remodelling and contractility. Long-term application of CCM seems to improve patients' exercise tolerance and quality of life. These benefits are apparently accomplished with an acceptable safety profile; however, to date, no data have demonstrated reductions in hospitalizations for heart failure or mortality. CCM is currently available in Europe and ongoing studies are attempting to identify the ideal target population and accumulate additional outcome data.

Programmed adsorption and release of proteins in a microfluidic device.

A microfluidic device has been developed that can adsorb proteins from solution, hold them with negligible denaturation, and release them on command. The active element in the device is a 4-nanometer-thick polymer film that can be thermally switched between an antifouling hydrophilic state and a protein-adsorbing state that is more hydrophobic. This active polymer has been integrated into a microfluidic hot plate that can be programmed to adsorb and desorb protein monolayers in less than 1 second. The rapid response characteristics of the device can be manipulated for proteomic functions, including preconcentration and separation of soluble proteins on an integrated fluidics chip.