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Importance: Barriers to heart transplant must be overcome prior to listing. It is unclear why Black men and women remain less likely to receive a heart transplant after listing than White men and women. Objective: To evaluate whether race or gender of a heart transplant candidate (ie, patient on the transplant waiting list) is associated with the probability of a donor heart being accepted by the transplant center team with each offer. Design, Setting, and Participants: This cohort study used the United Network for Organ Sharing datasets to identify organ acceptance with each offer for US non-Hispanic Black (hereafter, Black) and non-Hispanic White (hereafter, White) adults listed for heart transplant from October 18, 2018, through March 31, 2023. Exposures: Black or White race and gender (men, women) of a heart transplant candidate. Main Outcomes and Measures: The main outcome was heart offer acceptance by the transplant center team. The number of offers to acceptance was assessed using discrete time-to-event analyses, nonparametrically (stratified by race and gender) and parametrically. The hazard probability of offer acceptance for each offer was modeled using generalized linear mixed models adjusted for candidate-, donor-, and offer-level variables. Results: Among 159â¯177 heart offers with 13â¯760 donors, there were 14â¯890 candidates listed for heart transplant; 30.9% were Black, 69.1% were White, 73.6% were men, and 26.4% were women. The cumulative incidence of offer acceptance was highest for White women followed by Black women, White men, and Black men (P < .001). Odds of acceptance were less for Black candidates than for White candidates for the first offer (odds ratio [OR], 0.76; 95% CI, 0.69-0.84) through the 16th offer. Odds of acceptance were higher for women than for men for the first offer (OR, 1.53; 95% CI, 1.39-1.68) through the sixth offer and were lower for the 10th through 31st offers. Conclusions and Relevance: The cumulative incidence of heart offer acceptance by a transplant center team was consistently lower for Black candidates than for White candidates of the same gender and higher for women than for men. These disparities persisted after adjusting for candidate-, donor-, and offer-level variables, possibly suggesting racial and gender bias in the decision-making process. Further investigation of site-level decision-making may reveal strategies for equitable donor heart acceptance.
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Negro ou Afro-Americano , Disparidades em Assistência à Saúde , Insuficiência Cardíaca , Transplante de Coração , Obtenção de Tecidos e Órgãos , População Branca , Adulto , Feminino , Humanos , Masculino , Negro ou Afro-Americano/estatística & dados numéricos , Estudos de Coortes , Transplante de Coração/estatística & dados numéricos , Fatores Sexuais , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Doadores de Tecidos/estatística & dados numéricos , Estados Unidos/epidemiologia , Listas de Espera , População Branca/estatística & dados numéricos , Fatores Raciais , Disparidades em Assistência à Saúde/etnologia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/etnologia , Insuficiência Cardíaca/cirurgiaRESUMO
Heart failure continues to account for millions of cases and deaths worldwide. Heart transplant is the gold standard for treatment of advanced heart failure. Unfortunately, the supply of donor hearts continues to be limited with the increase in demand for heart transplantation. In this review, we aim to explore the safety and efficacy of using hearts from donors with history of substance use. Despite the theoretical effect of cocaine and alcohol on the cardiovascular system, several studies demonstrate no difference in outcomes (overall survival, graft rejection, graft vasculopathy) when using hearts from patients with history of cocaine and alcohol use. The opioid epidemic has expanded the potential donor pool where the current studies have not shown any adverse outcomes when considering donors with history of opioid use. The currently available evidence would support the use of donor hearts from patients with history of alcohol, cocaine, opioids, and marijuana use. Further studies are needed to evaluate the safety of using donor hearts from patients with history of nicotine use.
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Cocaína , Insuficiência Cardíaca , Transplante de Coração , Transtornos Relacionados ao Uso de Substâncias , Humanos , Transplante de Coração/efeitos adversos , Doadores de Tecidos , Insuficiência Cardíaca/cirurgia , Transtornos Relacionados ao Uso de Substâncias/complicações , Etanol , Estudos RetrospectivosRESUMO
Despite left ventricular assist device (LVAD) therapy becoming established for end-stage heart failure (HF), complications remain. Thromboembolic complications are rare with the newest iteration of LVADs. We managed a case of a continuous-flow LVAD-related thromboembolic event that presented as an acute myocardial infarction. A 64-year-old male who underwent Heartmate III® LVAD implantation had crushing substernal chest pain and ventricular tachycardia with acute anterolateral myocardial infarction on electrocardiogram on post-operative day 9. Echocardiography showed closed aortic valve and mild aortic regurgitation, but CT angiography showed thrombus within the left coronary cusp despite full anticoagulation. Continuous suction of blood from the left ventricle despite pulsatile flow into the ascending aorta resulted in a minimally opening aortic valve and stagnation of blood leading to thrombosis on the coronary cusp. Apart from post-operative ventricular tachycardia and right ventricular failure, he had adequate body size (body surface area 2.13 m2) and no post-operative or coagulopathy which could predispose him to thrombosis. Coronary angiography revealed stable severe three-vessel disease and thrombus in left main and proximal circumflex artery, and he had aspiration thrombectomy, and international normalized ratio target was increased to 3-3.5 with aspirin 325 mg daily. He survived to discharge but died 60 days after LVAD implant with multiple low flow alarms, and cardiac arrest. We review the literature and propose a management algorithm for patients with impaired AV opening and aortic root thrombosis.
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Insuficiência Cardíaca , Coração Auxiliar , Infarto do Miocárdio com Supradesnível do Segmento ST , Taquicardia Ventricular , Tromboembolia , Trombose , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Aorta Torácica , Trombose/etiologia , Valva Aórtica , Insuficiência Cardíaca/cirurgia , Taquicardia Ventricular/complicações , Coração Auxiliar/efeitos adversosRESUMO
Racial, ethnic, and gender disparities are present in the diagnosis and management of valvular heart disease. The prevalence of valvular heart disease varies by race, ethnicity, and gender, but diagnostic evaluations are not equitable across the groups, which makes the true prevalence less clear. The delivery of evidence-based treatments for valvular heart disease is not equitable. This article focuses on the epidemiology of valvular heart diseases associated with heart failure and the related disparities in treatment, with a focus on how to improve delivery of nonpharmacological and pharmacological treatments.
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Insuficiência Cardíaca , Doenças das Valvas Cardíacas , Humanos , Doenças das Valvas Cardíacas/epidemiologia , Doenças das Valvas Cardíacas/terapia , Etnicidade , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Disparidades em Assistência à SaúdeRESUMO
Clinical course and outcomes of myocarditis after COVID-19 vaccination remain variable. We retrospectively collected data on patients > 12 years old from 01/01/2021 to 12/30/2021 who received COVID-19 messenger RNA (mRNA) vaccination and were diagnosed with myocarditis within 60 days of vaccination. Myocarditis cases were based on case definitions by authors. We report on 238 patients of whom most were male (n = 208; 87.1%). The mean age was 27.4 ± 16 (range 12-80) years. Females presented at older ages (41.3 ± 21.5 years) than men 25.7 ± 14 years (p = 0.001). In patients > 20 years of age, the mean duration from vaccination to symptoms was 4.8 days ± 5.5 days, but in < 20, it was 3.0 ± 3.3 days (p = 0.04). Myocarditis occurred most commonly after the Pfizer-BioNTech mRNA vaccine (n = 183; 76.45) and after the second dose (n = 182; 80%). Symptoms started 3.95 ± 4.5 days after vaccination. The commonest symptom was chest pain (n = 221; 93%). Patients were treated with non-steroidal anti-inflammatory drugs (n = 105; 58.3%), colchicine (n = 38; 21.1%), or glucocorticoids (n = 23; 12.7%). About 30% of the patients had left ventricular ejection fraction but more than half recovered the on repeat imaging. Abnormal cardiac MRIs were common; 168 patients (96% of 175 patients that had MRI) had late gadolinium enhancement, while 120 patients (68.5%) had myocardial edema. Heart failure guideline-directed medical therapy use was common (n = 27; 15%). Eleven patients had cardiogenic shock; and 4 patients required mechanical circulatory support. Five patients (1.7%) died; of these, 3 patients had endomyocardial biopsy/autopsy-confirmed myocarditis. Most cases of COVID-19 vaccine myocarditis are mild. Females presented at older ages than men and duration from vaccination to symptoms was longer in patients > 20 years. Cardiogenic shock requiring mechanical circulatory support was seen and mortality was low. Future studies are needed to better evaluate risk factors, and long-term outcomes of COVID-19 mRNA vaccine myocarditis.
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Vacinas contra COVID-19 , COVID-19 , Miocardite , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , Anti-Inflamatórios/uso terapêutico , COVID-19/prevenção & controle , Vacinas contra COVID-19/efeitos adversos , Vacinas de mRNA/efeitos adversos , Miocardite/induzido quimicamente , Estudos Retrospectivos , RNA Mensageiro , Choque Cardiogênico/terapia , Volume Sistólico , Vacinação/efeitos adversos , Função Ventricular EsquerdaRESUMO
The impact of SARS-CoV-2 infection on heart transplant recipients is unknown. Literature is limited to case reports and series. The purpose of this study is to identify the clinical features, outcomes, and immunosuppression strategies of heart transplant recipients with COVID-19 infection. A systematic review was conducted using the search term "Coronavirus" or COVID," "SARS-CoV-2," "cardiac transplantation," and "heart transplant." Case reports and retrospective studies were gathered by searching Medline/PubMed, Google Scholar, CINAHL, Cochrane CENTRAL, and Web of Science. Thirty-three articles were selected for review. We identified 74 cases of SARS-CoV-2 infection in heart transplant and heart-kidney transplant recipients. The mean age was 60.5 ± 15.8 years, and 82.4% were males with median time from transplant of 6.5 years. Commonest symptoms were fever, cough, and dyspnea, but new left ventricular (LV) dysfunction was rare. Leukocytosis, lymphopenia, elevated inflammatory markers, and bilateral ground-glass opacities were common. Mortality was high, with particularly poor survival in patients who required intensive care unit (ICU) admission and older patients. Immunosuppression involved discontinuation of antimetabolites and steroids. COVID-19 infection in heart transplant (HT) recipients presents similarly to the general population, but new onset of LV dysfunction is uncommon. Immunosuppression strategies include increase in corticosteroids and discontinuation of antimetabolites.
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COVID-19 , Transplante de Coração , Adulto , Idoso , Antimetabólitos , Feminino , Transplante de Coração/efeitos adversos , Humanos , Terapia de Imunossupressão/efeitos adversos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , SARS-CoV-2 , TransplantadosRESUMO
Myocardial injury, diagnosed by troponin elevation, is common in COVID-19 patients, but cardiac involvement with clinical manifestations occurs less frequently. We analyzed the literature on COVID-19 (2020) and systematically reviewed the cases where individual patient data were presented. We searched PubMed and Google Scholar for "COVID," "COVID-19," and "coronavirus" in combination with "myocarditis," "heart failure," "takotsubo," "cardiomyopathy," and "cardiogenic shock." We identified 90 cases of COVID-19 with myocardial involvement, mean age 52.9 ± 18.3 years, 54.5% males. Of them, 55 survived (61.1%), 20 died (22.2%), and in 15 (16.7%) the outcome was unknown at the time of publication. Among patients with known outcome, mortality was 26%. The nadir LVEF was 31.7 ± 13.1% and recovered to 50.1 ± 16.0%. Pericardial effusion was a common finding, reported in 21 (23.3%) of patients, including moderate size effusion in 8.9% and large in 7.8%. The effusion caused tamponade in 11 (12.2%) of patients. Out of 83 patients who experienced a decrease in LVEF, 30 could be classified as takotsubo syndrome. The takotsubo patients were older than those with myocarditis, and with relatively high proportion of males. About one third of the cases was complicated by cardiogenic shock. Myocardial involvement in COVID-19 patients most often presents as a new, rapid decrease in LVEF, although normal LVEF or takotsubo-like wall motion pattern does not rule out myocarditis. Moderate and large pericardial effusion is common, and cardiac tamponade occurs in 12.2% of patients. Cardiogenic shock develops in one third of the patients. Mortality appears to be high at 26%.
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COVID-19 , Tamponamento Cardíaco , Miocardite , Derrame Pericárdico , Cardiomiopatia de Takotsubo , Adulto , Idoso , COVID-19/complicações , Tamponamento Cardíaco/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Miocardite/complicações , Derrame Pericárdico/complicações , Choque Cardiogênico/etiologia , Cardiomiopatia de Takotsubo/diagnósticoAssuntos
Insuficiência Cardíaca , Coração Auxiliar , Disfunção Ventricular Direita , Humanos , Artéria Pulmonar/diagnóstico por imagem , Artéria Pulmonar/cirurgia , Coração Auxiliar/efeitos adversos , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Background: Standard Modifiable Cardiovascular Risk Factors (SMuRF) such as hypertension, diabetes mellitus, hypercholesterolemia, and smoking have long been established in the etiology of atherosclerotic disease. Studies suggest that patients without any of these risk factors (SMuRF-less) who present with ST-elevation myocardial infarction have worse outcomes. Methods: The National Inpatient Sample databases (2016 to 2020) was queried to identify STEMI admissions as a principal diagnosis using ICD 10 codes. The study population aged 18 to 45 years were divided into cohorts of SMuRF and SMuRF-less based on the presence of ≥1 risk factor (hypertension, diabetes mellitus, hyperlipidemia, and smoking), and in-hospital outcomes were compared. Results: 41,990 patients were identified as the final study population. 38,495 patients were identified as SMuRF, and 3495 patients were SMuRF-less. Compared to SMuRF patients, SMuRF-less patients are more likely to be females (23.2 % vs. 21.2 %), have congestive heart failure (16.6 % vs. 13.7 %, p < 0.01) but less likely to have obesity (13.7 % vs 28.0 %, p < 0.01) In evaluating outcomes, SMuRF-less patients had higher adjusted in-hospital mortality (aOR 2.6, CI 1.5-4.2, p < 0.01), Cardiogenic shock (aOR 1.8, CI 1.3-2.5, p < 0.01), acute kidney injury (aOR 1.4, CI 1.0-1.9, p = 0.02), and Extramembrane Corporeal Oxygenation (aOR 4.1, CI 1.1-15.1, p = 0.03). Fluid and electrolyte abnormalities was an independent predictor of mortality among SMuRF-less patients (aOR 3.82, CI 1.3-11.2, p < 0.01). Conclusion: Young patients who present with STEMI and have no traditional cardiovascular risk factors have worse in-hospital outcomes. Further research is needed to evaluate the impact of non-traditional risk factors on acute myocardial infarction.
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Right heart failure (RHF) can result from many cardiac, pulmonary, and systemic pathologies. Common causes of RHF include pulmonary embolism, left heart failure, congenital heart disease, chronic lung disease, acute myocardial infarction, infiltrative disease, infectious disease, and valvular abnormalities. Acute and chronic RHF confer a high risk for morbidity and mortality in the acute care setting, and interventions commonly used in emergency care can prompt acute decompensation if the RHF is not recognized. The severity of presentation may range from compensated clinically silent cardiovascular dysfunction to venous congestion, multiorgan failure, and circulatory collapse. This review describes the pathophysiology of right heart failure and offers an evidence-based approach to the diagnosis, management, and disposition of both acute and chronic RHF.
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Serviços Médicos de Emergência , Insuficiência Cardíaca , Humanos , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/terapia , Serviço Hospitalar de Emergência , Pacientes , Cuidados CríticosRESUMO
It is unknown whether racial disparities in access to heart transplantation (HT) are amplified when coupled with substance use. We examined patients evaluated for HT over 8 years at an urban transplant center. We evaluated substance use and race/ethnicity as independent and interactive predictors of HT and left ventricular assist device (LVAD) implantation. Of 1,148 patients evaluated for HT, substance use was cited as an ineligibility factor in 151 (13%) patients, 16 (11%) of whom ultimately received HT. Significantly more non-Hispanic Black (NHB) patients were deemed ineligible due to substance use (n = 59, 19%) compared to other races/ethnicities (non-Hispanic white: n = 68, 12%; other race/ethnicity: n = 24, p = 0.002). No racial differences were observed in the likelihood of HT among patients initially excluded for substances, but more NHB patients ultimately received LVAD than the other racial groups. This study encourages greater awareness of the role of substance use and race in the HT evaluation.
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Transplante de Coração , Coração Auxiliar , Transtornos Relacionados ao Uso de Substâncias , Humanos , Transplante de Coração/estatística & dados numéricos , Masculino , Feminino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/etnologia , Adulto , Estudos Retrospectivos , População Branca/estatística & dados numéricos , Negro ou Afro-Americano/estatística & dados numéricos , Grupos Raciais/estatística & dados numéricos , Idoso , Disparidades em Assistência à Saúde/etnologia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Insuficiência Cardíaca/cirurgia , Insuficiência Cardíaca/etnologiaRESUMO
Pulmonary hypertension associated with left heart disease (PH-LHD) remains the most common cause of pulmonary hypertension globally. Etiologies include heart failure with reduced and preserved ejection fraction and left-sided valvular heart diseases. Despite the increasing prevalence of PH-LHD, there remains a paucity of knowledge about the hemodynamic definition, diagnosis, treatment modalities, and prognosis among clinicians. Moreover, clinical trials have produced mixed results on the usefulness of pulmonary vasodilator therapies for PH-LHD. In this expert review, we have outlined the critical role of meticulous hemodynamic evaluation and provocative testing for cases of diagnostic uncertainty. Therapeutic strategies-pharmacologic, device-based, and surgical therapies used for managing PH-LHD-are also outlined. PH-LHD in advanced heart failure, and the role of mechanical circulatory support in PH-LHD is briefly explored. An in-depth understanding of PH-LHD by all clinicians is needed for improved recognition and outcomes among patients with PH-LHD.
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Insuficiência Cardíaca , Hipertensão Pulmonar , Humanos , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/terapia , Hipertensão Pulmonar/etiologia , Hipertensão Pulmonar/fisiopatologia , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/terapia , Insuficiência Cardíaca/complicações , Vasodilatadores/uso terapêutico , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/terapia , Disfunção Ventricular Esquerda/fisiopatologia , Disfunção Ventricular Esquerda/etiologia , Coração Auxiliar , Hemodinâmica/fisiologia , Gerenciamento ClínicoRESUMO
Cardiac cachexia is characterized by unintentional catabolic weight loss, decreased appetite, and inflammation and is common in patients with stage D (advanced) heart failure with reduced ejection fraction (HFrEF). Cardiac cachexia and related muscle-wasting syndromes are markers of, and a consequence of, the heart failure (HF) syndrome. Although many potential modalities for identifying cardiac cachexia exist, the optimal definition, diagnostic tools, and treatment options for cardiac cachexia remain unclear. Furthermore, it remains unclear whether attempts to reverse muscle wasting prior to advanced HF surgeries, such as left ventricular assist devices and heart transplantation, can improve outcomes. It is important that HF clinicians and dietitians are aware of the pathophysiology and mechanisms of muscle-wasting syndromes in patients with HF, to aid in the recognition and risk stratification of advanced HFrEF. Although the opportunities and rationale for attempting to address cardiac cachexia prior to advanced HF surgeries are uncertain, recent publications suggest that control of the neurohumoral syndrome of advanced HF may be important to permit the recovery of skeletal muscle mass.
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Iron deficiency (ID) is present in approximately 50% of patients with heart failure (HF) and even higher prevalence rate up to 80% in post-acute HF setting. The current guidelines for HF recommend intravenous (IV) iron replacement in HF with reduced or mildly reduced ejection fraction and ID based on clinical trials showing improvements in quality of life and exercise capacity, and an overall treatment benefit for recurrent HF hospitalization. However, several barriers cause challenges in implementing IV iron supplementation in practice due, in part, to clinician knowledge gaps and limited resource availability to protocolize routine utilization in appropriate patients. Thus, the current review will discuss practical considerations in ID treatment, implementation of evidence-based ID treatment to improve regional health disparities with toolkits, inclusion/exclusion criteria of IV iron supplementation, and clinical controversies in ID treatment, as well as gaps in evidence and questions to be answered.
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Black patients develop heart failure at younger ages and have worse outcomes such as higher mortality rates compared to other racial and ethnic groups in the United States. Despite significant recent improvements in heart failure medical therapy, these worse outcomes have persisted. Multiple reasons have been provided to explain the situation, including but not limited to higher baseline cluster of cardiovascular risk factors amongst Black patients, inadequate use of heart failure guideline directed medical therapy and delayed referral for advanced heart failure therapies and interventions. Strategic interventions considering social and structural determinants of health, addressing structural inequalities/ bias, implementation of quality improvement programs, early diagnosis and prevention are critically needed to bridge the racial/ ethnic disparities gap and improve longevity of Black patients with heart failure. In this review, we propose evidence-based solutions that provide a framework for the primary care physician addressing these challenges to engender equity in treatment allocation and improve outcomes for all patients with heart failure.
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BACKGROUND: Myocarditis, diagnosed by symptoms and troponin elevation, has been well-described with COVID-19 infection, as well as shortly after COVID-19 vaccination. The literature has characterized the outcomes of myocarditis following COVID-19 infection and vaccination, but clinicopathologic, hemodynamic, and pathologic features following fulminant myocarditis have not been well-characterized. We aimed to compare clinical and pathological features of fulminant myocarditis requiring hemodynamic support with vasopressors/inotropes and mechanical circulatory support (MCS), in these two conditions. METHODS: We analyzed the literature on fulminant myocarditis and cardiogenic shock associated with COVID-19 and COVID-19 vaccination and systematically reviewed all cases and case series where individual patient data were presented. We searched PubMed, EMBASE, and Google Scholar for "COVID", "COVID-19", and "coronavirus" in combination with "vaccine", "fulminant myocarditis", "acute heart failure", and "cardiogenic shock". The Student's t-test was used for continuous variables and the χ2 statistic was used for categorical variables. For non-normal data distributions, the Wilcoxon Rank Sum Test was used for statistical comparisons. RESULTS: We identified 73 cases and 27 cases of fulminant myocarditis associated with COVID-19 infection (COVID-19 FM) and COVID-19 vaccination (COVID-19 vaccine FM), respectively. Fever, shortness of breath, and chest pain were common presentations, but shortness of breath and pulmonary infiltrates were more often present in COVID-19 FM. Tachycardia, hypotension, leukocytosis, and lactic acidosis were seen in both cohorts, but patients with COVID-19 FM were more tachycardic and hypotensive. Histologically, lymphocytic myocarditis dominated both subsets, with some cases of eosinophilic myocarditis in both cohorts. Cellular necrosis was seen in 44.0% and 47.8% of COVID-19 FM and COVID-19 vaccine FM, respectively. Vasopressors and inotropes were used in 69.9% of COVID-19 FM and in 63.0% of the COVID-19 vaccine FM. Cardiac arrest was observed more in COVID-19 FM (p = 0.008). Venoarterial extracorporeal membrane oxygenation (VA-ECMO) support for cardiogenic shock was also used more commonly in the COVID-19 fulminant myocarditis group (p = 0.0293). Reported mortality was similar (27.7%) and 27.8%, respectively) but was likely worse for COVID-19 FM as the outcome was still unknown in 11% of cases. CONCLUSIONS: In the first series to retrospectively assess fulminant myocarditis associated with COVID-19 infection versus COVID-19 vaccination, we found that both conditions had a similarly high mortality rate, while COVID-19 FM had a more malignant course with more symptoms on presentation, more profound hemodynamic decompensation (higher heart rate, lower blood pressure), more cardiac arrests, and higher temporary MCS requirements including VA-ECMO. In terms of pathology, there was no difference in most biopsies/autopsies that demonstrated lymphocytic infiltrates and some eosinophilic or mixed infiltrates. There was no predominance of young males in COVID-19 vaccine FM cases, with male patients representing only 40.9% of the cohort.
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Sickle cell disease (SCD) is the most common hereditary hemoglobinopathy and mainly affects individuals of African ancestry. As survival has improved especially in high-income countries, increased rates of cardiopulmonary complications such as pulmonary hypertension, heart failure with diastolic dysfunction, and sudden death are encountered in clinical practice. These complications are the leading causes of morbidity and mortality as these individuals survive into adulthood. Understanding the need for, early identification, timely intervention, and implementation of preventive strategies are critical in reversing this trend and improving quality of life and survival rates. This manuscript aims to provide a comprehensive review of the pathogenesis of cardiovascular complications associated with sickle cell disease and equip the clinician with tools to facilitate the early diagnosis and management of patients with SCD as increasing numbers survive into adulthood.
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BACKGROUND: Durable left ventricular assist devices (VADs) improve survival in eligible patients, but allocation has been associated with patient race in addition to presumed heart failure (HF) severity. OBJECTIVES: This study sought to determine racial and ethnic differences in VAD implantation rates and post-VAD survival among patients with ambulatory HF. METHODS: Using the INTERMACS (Interagency Registry of Mechanically Assisted Circulatory Support) database (2012-2017), this study examined census-adjusted VAD implantation rates by race, ethnicity, and sex in patients with ambulatory HF (INTERMACS profile 4-7) using negative binomial models with quadratic effect of time. Survival was evaluated using Kaplan-Meier estimates and Cox models adjusted for clinically relevant variables and an interaction of time with race/ethnicity. RESULTS: VADs were implanted in 2,256 adult patients with ambulatory HF (78.3% White, 16.4% Black, and 5.3% Hispanic). The median age at implantation was lowest in Black patients. Implantation rates peaked between 2013 and 2015 before declining in all demographic groups. From 2012 to 2017, implantation rates overlapped for Black and White patients but were lower for Hispanic patients. Post-VAD survival was significantly different among the 3 groups (log rank P = 0.0067), with higher estimated survival among Black vs White patients (12-month survival: Black patients: 90% [95% CI: 86%-93%]; White patients: 82% [95% CI: 80%-84%]). Low sample size for Hispanic patients resulted in imprecise survival estimates (12-month survival: 85% [95% CI: 76%-90%]). CONCLUSIONS: Black and White patients with ambulatory HF had similar VAD implantation rates but rates were lower for Hispanic patients. Survival differed among the 3 groups, with the highest estimated survival at 12 months in Black patients. Given higher HF burden in minoritized populations, further investigation is needed to understand differences in VAD implantation rates in Black and Hispanic patients.