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Background: United Network for Organ Sharing (UNOS) allocation criteria changed in 2018 to accommodate the increased prevalence of patients on a ventricular assist device as a bridge to heart transplant and prioritize sicker people in anticipation of a heart graft. We aimed to assess the impact of patient age in the new allocation policy on mortality following heart transplantation. Secondary outcomes included the effect of age ≥70 on post‐transplant events, including stroke, dialysis, pacemaker, and rejection requiring treatment. Methods: The UNOS Registry was queried to identify patients who underwent heart transplants alone in the US between 2000 and 2021. Patients were divided into groups according to their age (over 70 and under 70 years old). Results: Patients aged over 70 were more likely to require dialysis during follow‐up, but less likely to experience rejection requiring treatment, compared with patients aged <70. Age ≥70 in the new allocation system was a significant predictor of 1‐year mortality (adjusted HR: 1.41; 95% CI: 1.05–1.91; p =.024), but its effect on 5‐year mortality was not significant after adjusting for potential confounders (adjusted HR: 1.27; 95% CI:.97–1.66; p =.077). Undergoing transplantation under the new allocation policy vs the old allocation policy was not a significant predictor of mortality in patients over 70 years old. Conclusions: Age ≥70 is a significant predictor of 1‐year mortality following heart transplantation, but not at 5 and 10 years; however, the new allocation does not seem to have changed the outcomes for this group of patients. [ABSTRACT FROM AUTHOR]

The 2018 heart allocation system has significantly influenced heart transplantation and left ventricular assist device (LVAD) utilization. Our study aims to investigate age-related outcomes following LVAD implantation in the post-allocation era. Using the National Inpatient Sample, we analyzed data from 7375 patients who underwent LVAD implantation between 2019 and 2020. The primary endpoint was in-hospital mortality following LVAD implantation, stratified by age categories. The age groups were 18–49, 50–59, 60–69, and over 70. These represented 26%, 26%, 31%, and 17% of patients, respectively. Patients aged 60–69 and those over 70 exhibited higher in-hospital mortality rates of 12% and 17%, respectively, compared to younger age groups (7% for 18–49 and 6% for 50–59). The age groups 60–69 and over 70 were independent predictors of mortality, with adjusted odds ratios of 1.99 (p = 0.02; 95% confidence interval [CI], 1.12–3.57) and 2.88 (p = 0.002; 95% CI, 1.45–5.71), respectively. Additionally, a higher Charlson Comorbidity Index was associated with increased in-hospital mortality risk (adjusted odds ratio 1.39; p = 0.02; 95% CI, 1.05–1.84). Additionally, patients above 70 experienced a statistically shorter length of stay. Nonhome discharge was found to be significantly high across all age categories. However, the difference in hospitalization cost was not statistically significant across the age groups. Our study highlights that patients aged 60 and above face an increased risk of in-hospital mortality following LVAD implantation in the post-allocation era. This study sheds light on age-related outcomes and emphasizes the importance of considering age in LVAD patient selection and management strategies. [ABSTRACT FROM AUTHOR]

(1) Background: Heart failure is an extremely impactful health issue from both a social and quality-of-life point of view and the rate of patients with this condition is destined to rise in the next few years. Transplantation remains the mainstay of treatment for end-stage heart failure, but a shortage of organs represents a significant problem that prolongs time spent on the waiting list. In view of this, the selection of donor and recipient must be extremely meticulous, considering all factors that could predispose to organ failure. One of the main considerations regarding heart transplants is the risk of graft rejection and the need for immunosuppression therapy to mitigate that risk. In this study, we aimed to assess the characteristics of patients who need immunosuppression treatment for rejection within one year of heart transplantation and its impact on mid-term and long-term mortality. (2) Methods: The United Network for Organ Sharing (UNOS) Registry was queried to identify patients who solely underwent a heart transplant in the US between 2000 and 2021. Patients were divided into two groups according to the need for anti-rejection treatment within one year of heart transplantation. Patients' characteristics in the two groups were assessed, and 1 year and 10 year mortality rates were compared. (3) Results: A total of 43,763 patients underwent isolated heart transplantation in the study period, and 9946 (22.7%) needed anti-rejection treatment in the first year. Patients who required treatment for rejection within one year after transplant were more frequently younger (49 ± 14 vs. 52 ± 14 years, p < 0.001), women (31% vs. 23%, p < 0.001), and had a higher CPRA value (14 ± 26 vs. 11 ± 23, p < 0.001). Also, the rate of prior cardiac surgery was more than double in this group (27% vs. 12%, p < 0.001), while prior LVAD (12% vs. 11%, p < 0.001) and IABP (10% vs. 9%, p < 0.01) were more frequent in patients who did not receive anti-rejection treatment in the first year. Finally, pre-transplantation creatinine was significantly higher in patients who did not need treatment for rejection in the first year (1.4 vs. 1.3, p < 0.01). Most patients who did not require anti-rejection treatment underwent heart transplantation during the new allocation era, while less than half of the patients who required treatment underwent transplantation after the new allocation policy implementation (65% vs. 49%, p < 0.001). Patients who needed rejection treatment in the first year had a higher risk of unadjusted 1 year (HR: 2.25; 95% CI: 1.88–2.70; p < 0.001), 5 year (HR: 1.69; 95% CI: 1.60–1.79; p < 0.001), and 10 year (HR: 1.47; 95% CI: 1.41–1.54, p < 0.001) mortality, and this was confirmed at the adjusted analysis at all three time-points. (4) Conclusions: Medical treatment of acute rejection was associated with significantly increased 1 year mortality compared to patients who did not require anti-rejection therapy. The higher risk of mortality was confirmed at a 10 year follow-up. Further studies and newer follow-up data are required to investigate the role of anti-rejection therapy in the heart transplant population. [ABSTRACT FROM AUTHOR]

Background: United Network for Organ Sharing (UNOS) allocation criteria changed in 2018 to accommodate the increased prevalence of ventricular assist device use as a bridge to heart transplant, which consequently prioritized sicker patients. We aimed to assess the impact of this new allocation policy on the length of stay following heart transplantation. Secondary outcomes include other risk factors for prolonged hospitalization and its effect on mortality and postoperative complications. Methods: The UNOS Registry was queried to identify patients who underwent isolated heart transplants in the United States between 2001 and 2023. Patients were divided into quartiles according to their respective length of stay. Results: A total of 57 020 patients were included, 15 357 of which were allocated with the new system. The median hospital length of stay was 15 days (mean 22.7 days). Length of stay was longer in the new allocation era (25 ± 30 vs. 22 ± 27 days, p <.001). The longer length of stay was associated with increased 5‐year mortality in the new allocation system (aHR: 1.18; 95% CI: 1.15, 1.20; p‐value: <.001). Conclusion: Longer hospital stays and associated observed increased risk for mortality in the era after the allocation criteria change reflect the rationale of this shift which was to prioritize heart transplants for sicker patients. Further studies are needed to track the progress of surgical and perioperative management of these studies over time. [ABSTRACT FROM AUTHOR]

Transesophageal echocardiography is the most frequently used imaging modality for exclusion of left atrial appendage thrombus prior to cardioversion. Echocardiographers should be aware of rare conditions that may mimic left atrial appendage thrombus. Here, we describe a rare case of prominent para‐cardiac fat mimicking left atrial appendage thrombus on transesophageal echocardiographic imaging. Multimodality imaging with cardiac computed tomography was instrumental in providing further anatomical delineation and characterization of the echodensity as prominent para‐cardiac fat in this case. [ABSTRACT FROM AUTHOR]

Background: Patients on the waiting list for heart transplantation (HT) can become inactive or made status seven because of medical reasons, such adverse events, complications, or psychosocial circumstances. If the condition that caused the inactivation is resolved, patients are re‐ activated. Information about the prognostic implications of Status 7 in the new donor heart allocation system has not been described. To bridge this knowledge gap, we performed an analysis of the United Network of Organ Sharing (UNOS) registry. Methods: Data on adult patients who underwent HT between October 18th, 2018 and October 2021, were queried from the UNOS registry. The main outcomes were post‐ transplant all‐cause mortality, 1‐year all‐cause mortality and treated acute rejection. Since re‐transplantation is a competing event for all‐cause mortality, we performed competing risk survival analysis and reported sub distribution hazard ratios (SHR) from the Fine and Gray model to examine the relationship between inactive status and all‐cause mortality. Results: A total of 5267 adult patients underwent HT and were previously listed as Status 1 or Status 2 in the new allocation system. We identified 946 HT recipients temporarily inactivated while on HT list (18%). The number of temporarily inactive patients remained stable since the implementation of the new donor allocation system (p =.37). Approximately, two‐thirds of temporarily inactive patients (65.9%) were inactivated for being too sick, whereas other frequent justifications for inactivity included left ventricular assist device implantation (7.8%) and insurance related issues (4.8%). Temporarily inactive HT recipients were more likely to be African Americans, males, have a higher body mass index (BMI) and significantly longer waiting time (391.6 ± 600 vs. 72.3 ± 223 days, p <.001) compared with never inactivated patients. In the unadjusted analyses 30‐day mortality did not differ between groups, but both 1‐year and overall all‐cause mortality was significantly higher in temporarily inactive patients (1‐year: SHR: 1.3; 95% confidence intervals [CI]: 1.03, 1.64; p =.028, overall mortality SHR: 1.31; 95% CI: 1.06, 1.64; p =.014). After adjustment for donor and recipient characteristics, a trend towards higher 1‐year and overall mortality remained (1‐year: SHR 1.32; 95% CI.99, 1.76, p =.006, overall mortality SHR: 1.29; 95% CI:.98–1.68, p =.065). No differences in treated acute allograft rejection at 1 year were found between groups. Conclusions: Temporary inactive status while waiting for HT occurs in approximately one in five HT recipients listed in higher urgency categories after the implementation of the new allocation system. A signal of adverse long‐term outcomes was found, and this could be explained by differences in recipient characteristics. Further research is required to elucidate pathways involved and possible implications for clinical practice. [ABSTRACT FROM AUTHOR]

Background: Machine learning (ML) is increasingly being applied in Cardiology to predict outcomes and assist in clinical decision‐making. We sought to develop and validate an ML model for the prediction of mortality after heart transplantation (HT) in adults with congenital heart disease (ACHD). Methods: The United Network for Organ Sharing (UNOS) database was queried from 2000 to 2020 for ACHD patients who underwent isolated HT. The study cohort was randomly split into derivation (70%) and validation (30%) datasets that were used to train and test a CatBoost ML model. Feature selection was performed using SHapley Additive exPlanations (SHAP). Recipient, donor, procedural, and post‐transplant characteristics were tested for their ability to predict mortality. We additionally used SHAP for explainability analysis, as well as individualized mortality risk assessment. Results: The study cohort included 1033 recipients (median age 34 years, 61% male). At 1 year after HT, there were 205 deaths (19.9%). Out of a total of 49 variables, 10 were selected as highly predictive of 1‐year mortality and were used to train the ML model. Area under the curve (AUC) and predictive accuracy for the 1‐year ML model were.80 and 75.2%, respectively, and.69 and 74.2% for the 3‐year model, respectively. Based on SHAP analysis, hemodialysis of the recipient post‐HT had overall the strongest relative impact on 1‐year mortality after HΤ, followed by recipient‐estimated glomerular filtration rate, age and ischemic time. Conclusions: ML models showed satisfactory predictive accuracy of mortality after HT in ACHD and allowed for individualized mortality risk assessment. [ABSTRACT FROM AUTHOR]

Background: Right ventricular failure (RVF) continues to affect patients supported with durable left ventricular assist devices (LVAD) and results in increased morbidity and mortality. Information regarding the impact of right ventricular response to pre-operative optimization on outcomes is scarce. Methods: Single-center retrospective analysis of consecutive patients who underwent first continuous flow LVAD implantation between 2006 and 2020. Patients with bi-ventricular support before LVAD or without hemodynamic data were excluded. Invasive hemodynamics at baseline and after pre-operative medical and/or temporary circulatory support were recorded. Patients were grouped in the following categories: A: No Hemodynamic RV dysfunction (RVD) at baseline; B: RVD with achievement of RV hemodynamic optimization goals; C: RVD without achievement of RV optimization goals. The main outcomes were right ventricular failure defined as inotropes >14 days after implantation, or postoperative right ventricular mechanical support, and all-cause mortality. Results: Overall, 128 patients were included in the study. The mean age was 58 ± 12.5 years, 74.2% were males and, 68.7% had non-ischemic cardiomyopathy. Hemodynamic RVD was present in 70 (54.7%) of the patients at baseline. RV hemodynamic goals were achieved in 46 (79.31%) patients with RVD and in all the patients without RVD at baseline. Failure to achieve hemodynamic optimization goals was associated with a significantly higher risk of RVF after LVAD implantation (adjusted OR 4.37, 95% CI 1.14–16.76, p = 0.031) compared with no RVD at baseline and increased 1-year mortality compared with no RVD (adjusted HR 4.1, 95% CI 1.24–13.2, p = 0.02) and optimized RVD (adjusted HR 6.4, 95% CI 1.6–25.2, p = 0.008).Conclusion: Among patients with RVD, the inability to achieve hemodynamic optimization goals was associated with higher rates of RV failure and increased 1-year all-cause mortality post LVAD implantation. [ABSTRACT FROM AUTHOR]

Background: Patients with left ventricular assist devices (LVADs) are anticoagulated with warfarin and may receive enoxaparin bridging for a subtherapeutic international normalized ratio (INR). There is no guideline regarding enoxaparin bridging in LVAD patients and a dosing strategy to ensure efficacy and safety is uncertain. Objective: The objective was to characterize the use of enoxaparin bridging for subtherapeutic INRs and its impact on thrombotic or major bleeding events (MBE) in patients with an LVAD. Methods: A retrospective review from 6/1/17 to 6/30/18 was performed. Patients with an LVAD were excluded if they had less than 60 days of outpatient anticoagulation or age <18 years old. Patients were divided into 2 cohorts based on enoxaparin exposure. MBE and thrombotic events were classified as related to enoxaparin if events occurred while receiving enoxaparin and up to 7 days or 30 days, respectively, after discontinuation. Results: Seventy-one LVAD patients met inclusion criteria and 50 patients received enoxaparin bridging. Therapeutic-dose enoxaparin was initiated at a mean INR of 1.8 for a mean duration of 2.8 days. In the enoxaparin exposure group, one MBE occurred 6 days after enoxaparin discontinuation, coinciding with an INR increase from 1.8 to 4.7. One thrombotic event occurred 2 days after enoxaparin discontinuation at an INR of 5.0. Conclusion: This institution's bridging strategy of therapeutic-dose enoxaparin with a short duration has a low rate of bleeding and thrombotic events. Additional prospective studies of anticoagulation bridging based on characteristics such as type of LVAD device are warranted. [ABSTRACT FROM AUTHOR]

Outflow cannula occlusion is an infrequent complication occurring among recipients of continuous flow left ventricular assist devices. Hereby, we present a case of a 66-year-old man with a HeartMate 3 left ventricular assist device that presented 18 months after implantation and during his admission, evidence of poor left ventricular unloading and forward flow uncovered intrinsic and extrinsic outflow cannula obstruction. The patient's course was complicated by cardiogenic shock, diffuse alveolar hemorrhage and multiorgan failure. Post-mortem examination suggested foreign body reaction as a potential contributor of outflow graft obstruction at the level of the bend relief. [ABSTRACT FROM AUTHOR]

Previous studies have reported superiority of mechanistic target-of-rapamycin (mTOR) antagonists (mTA) over calcineurin inhibitors (CNI) as part of maintenance immunosuppression (IS) in mitigating cardiac allograft vasculopathy (CAV) after heart transplantation (HT). MEDLINE and EMBASE were searched through October 2019 for studies comparing maintenance IS with mTA + antimetabolites (AM), CNI + mTA or CNI + AM post HT. The main outcomes were all-cause mortality, CAV, acute rejection, CMV infections, and change in eGFR. To compare different IS antagonists, a random-effects network meta-analysis was performed. We used p-scores to rank best treatments per outcome. Our search identified fifteen eligible studies (5 studies comparing mTA + AM vs. CNI + AM, 9 comparing CNI + mTA vs. CNI + AM, 1 comparing mTA + AM vs. CNI + mTA, 8 using everolimus and 7 sirolimus as mTA) reporting the selected outcomes. We did not identify any statistical difference in all-cause mortality among the three IS regimens without heterogeneity among studies. CAV rates were significantly lower with CNI + mTA (odds ratio [OR] 0.53, 95% confidence interval [CI] 0.3–0.92). Acute rejection rates were significantly lower with CNI + AM (OR 0.26, 95% CI 0.12–0.56) and with CNI + mTA (OR 0.16, 95% CI 0.07–0.33) compared with mTA + AM without significant heterogeneity (I2 = 43%, p = 0.9). CMV infections were significantly lower with mTA + AM (OR 0.13, 95% CI 0.03–0.46) and with CNI + mTA (OR 0.27, 95% CI 0.2–0.38) compared with CNI + AM without heterogeneity. mTA + AM led to higher eGFR compared with CNI + AM (9.06 ml/min/1.73 m2, 95% CI 3.15–14.97) and CNI + Mta (9.64 ml/min/1.73 m2, 95% CI 0.91–18.36), but the heterogeneity among studies was significant. CNI + mTA ranked better for CAV (p = 0.78), and acute rejection (p = 0.99) while mTA + AM for CMV infection (p = 0.94) and improvement in renal function (p = 0.93) than other regimens. Different IS regimens have similar effects on survival post HT, but CNI + mTA was associated with lower CAV rates, and acute rejection, while mTA + AM with less CMV infection post HT. [ABSTRACT FROM AUTHOR]

Direct oral anticoagulants (DOACs) are increasingly used in clinical practice and have become essential in the management of atrial fibrillation and VTE. The enthusiasm for DOACs has fueled the off-label application of these agents in cardiopulmonary disease, and their use has often outpaced the evidence supporting their application. This article reviews the evidence and current off-label use of DOACs in various cardiopulmonary disease states. [ABSTRACT FROM AUTHOR]

Background: We investigated the current trends and outcomes of diabetic patients listed for heart transplants in the U.S. and provided a method for risk‐stratification. Methods: Using data from the United Network for Organ Sharing (UNOS), we identified heart failure patients listed for heart transplants between 2010 and 2019. Diabetic patients were propensity‐matched with non‐diabetics, and waitlist mortality as well as post‐transplant graft survival were compared between the two groups. Further risk‐stratification of diabetic patients was done based on the risk factors that independently predict graft failure. Results: 28,928 adult patients (30% diabetic) with end‐stage heart failure were added to the waitlist over the study period. In the propensity‐matched cohort, waitlist mortality was higher in diabetic patients compared to non‐diabetics (HR = 1.13 (95% CI = 1.04‐1.22, P =.002). Over the study period, 5739 patients with diabetes were transplanted. In the propensity‐matched cohorts of transplant recipients, the rate of graft failure was significantly higher for diabetic patients (23.3%) compared to non‐diabetics (20.4%); HR = 1.17, 95% CI = 1.08‐1.26, P <.001. We identified 12 risk factors of graft failure among diabetic patients and developed a risk score that further risk‐stratify these patients. Diabetic patients at low risk (score≤4) had similar graft survival as patients without diabetes (HR =.91, 95% CI =.82‐1.01, P =.06). On the other hand, high‐risk diabetic patients had worse graft survival compared to non‐diabetics (HR = 1.52, 95% CI = 1.38‐1.67, P <.001). Conclusion: Among patients with end‐stage heart failure, pre‐existing diabetes was associated with higher waitlist mortality and worse graft survival. However, with careful patient selection, graft survival is similar to those without diabetes. [ABSTRACT FROM AUTHOR]

Background: The number of patients with sarcoidosis requiring heart transplantation (HT) is increasing. The aim of this study was to evaluate outcomes of isolated HT in patients with sarcoid cardiomyopathy and compare them to recipients with non‐ischaemic restrictive or dilated cardiomyopathy. Methods and results: Adult HT recipients were identified in the UNOS Registry between 1990 and 2020. Patients were grouped according to diagnosis. The cumulative incidences for the all‐cause mortality and rejection were compared using Fine and Gray model analysis, accounting for re‐transplantation as a competing risk. Rejection was evaluated using logistic regression analysis. We also reviewed characteristics and outcomes of all HT recipients with previous diagnosis of sarcoid cardiomyopathy from a single centre. A total of 30 160 HT recipients were included in the present study (n = 239 sarcoidosis, n = 1411 non‐ischaemic restrictive cardiomyopathy, and n = 28 510 non‐ischaemic dilated cardiomyopathy). During a total of 194 733 patient‐years, all‐cause mortality at the latest follow‐up was not significantly different when comparing sarcoidosis to non‐ischaemic dilated cardiomyopathy [adjusted subhazard ratio (aSHR) 1.46, 95% confidence intervals (CIs): 0.9–2.4, P = 0.12] or restrictive cardiomyopathy (aSHR 1.12, 95% CI: 0.65–1.95, P = 0.67). Accordingly, multivariable analysis suggested that 1 year mortality was not significantly different between sarcoidosis and non‐ischaemic dilated cardiomyopathy (aSHR 1.56, 95% CI: 0.9–2.7, P = 0.12) or restrictive cardiomyopathy (aSHR 1.15, 95% CI: 0.61–2.18, P = 0.66). No differences were observed regarding 30 day mortality, treated and hospitalized acute rejection, and 30 day death from graft failure after HT. Thirty‐day mortality did not improve significantly in more recent HT eras whereas there was a trend towards improved 1 year mortality in the latest HT era (P = 0.06). Data from the single‐centre case review showed excellent long‐term outcomes with sirolimus‐based immunosuppression. Conclusions: Short‐term and long‐term post HT outcomes among patients with sarcoid cardiomyopathy are similar to those with common types of non‐ischaemic cardiomyopathy. [ABSTRACT FROM AUTHOR]

Heart failure with reduced ejection fraction (HFrEF) is an increasing global pandemic affecting more than 30 million individuals worldwide. Importantly, HFrEF is frequently accompanied by the presence of cardiac and non-cardiac comorbidities that may greatly influence the management and prognosis of the disease. In this review article, we will focus on three important comorbidities in HFrEF; atrial fibrillation (AF), advanced renal disease, and elderly, which all have a paramount impact on progression of the disease, management strategies, and response to therapy. AF is very common in HFrEF and shares many risk factors. AF aggravates heart failure and contributes to HF-related adverse clinical outcomes; hence it requires special consideration in HFrEF management. The kidney function is largely affected by the reduced cardiac output developed in the setting of HFrEF, and the neurohormonal feedback effects create a complex interplay that pose challenges in the management of HFrEF when renal function is significantly impaired. Cardiorenal syndrome is a challenging sequela with increased morbidity and mortality thereby reflecting the delicate and complex balance between the heart and the kidney in HFrEF and renal failure conditions. Furthermore, patients with advanced renal failure have poor prognosis in the presence of HFrEF with limited treatment options. Finally, aging and frailty are important factors that influence treatment strategies in HFrEF with greater emphasis on tolerability and safety of the various HFrEF therapies in elderly individuals. [ABSTRACT FROM AUTHOR]

Background: Approximately 50% of heart transplant (HT) programs utilize induction therapy (IT) with interleukin‐2 receptor antagonists (IL2RA) or polyclonal anti‐thymocyte antibodies (ATG). Methods: Adult HT recipients were identified in the UNOS Registry between 2010 and 2020. We compared mortality between IT strategies with competing risk analysis. Results: A total of 28 634 HT recipients were included in the study (50.1% no IT, 21.3% ATG, 27.9% IL2RA,.7% alemtuzumab,.01% OKT3). Adjusted all‐cause, 30 day and 1 year mortality were lower among those treated with IT than no IT (sub‐hazard ratio [SHR].87, 95% CI.79–.96, SHR.86,.76–.97, SHR.76,.63–.93, P =.007, respectively). In propensity score matching analysis IT was associated with lower 30‐day and 1‐year mortality. IL2RA had higher all‐cause and 1‐year mortality than ATG (SHR 1.41, 95% CI 1.23–1.69 and 1.55, 95% CI 1.29–1.88, respectively). Utilization of IT was associated with significantly lower risk of treated rejection at 1 year after HT compared with no IT (relative risk ratio [RRR].79) and similarly ATG compared with IL2RA (RRR.51). Conclusion: IT was associated with lower mortality and treated rejection episodes than no IT. IL2RA is the most used IT approach but ATG has lower risk of treated rejection and mortality. [ABSTRACT FROM AUTHOR]

Background Post-operative stroke increases morbidity and mortality after cardiac surgery. Data on characteristics and outcomes of stroke after heart transplantation (HTx) are limited. Methods and results We conducted a retrospective analysis of the United Network for Organ Sharing (UNOS) database from 2009 to 2020 to identify adults who developed stroke after orthotropic HTx. Heart transplant recipients were divided according to the presence or absence of post-operative stroke. The primary endpoint was all-cause mortality. A total of 25 015 HT recipients were analysed, including 719 (2.9%) patients who suffered a post-operative stroke. The stroke rates increased from 2.1% in 2009 to 3.7% in 2019, and the risk of stroke was higher after the implantation of the new allocation system [odds ratio 1.29, 95% confidence intervals (CI) 1.06–1.56, P = 0.01]. HTx recipients with post-operative stroke were older (P = 0.008), with higher rates of prior cerebrovascular accident (CVA) (P = 0.004), prior cardiac surgery (P < 0.001), longer waitlist time (P = 0.04), higher rates of extracorporeal membrane oxygenation (ECMO) support (P < 0.001), left ventricular assist devices (LVADs) (P < 0.001), mechanical ventilation (P = 0.003), and longer ischaemic time (P < 0.001). After multivariable adjustment for recipient and donor characteristics, age, prior cardiac surgery, CVA, support with LVAD, ECMO, ischaemic time, and mechanical ventilation at the time of HTx were independent predictors of post-operative stroke. Stroke was associated with increased risk of 30 day and all-cause mortality (hazard ratio 1.49, 95% CI 1.12–1.99, P = 0.007). Conclusions Post-operative stroke after HTx is infrequent but associated with higher mortality. Redo sternotomy, LVAD, and ECMO support at HTx are among the risk factors identified. [ABSTRACT FROM AUTHOR]

In the context of the COVID-19 pandemic, many barriers to telemedicine disappeared. Virtual visits and telemonitoring strategies became routine. Evidence is accumulating regarding the safety and efficacy of virtual visits to replace in-person visits. A structured approach to virtual encounters is recommended. Telemonitoring includes patient reported remote vital sign monitoring, information from wearable devices, cardiac implantable electronic devices and invasive remote hemodynamic monitoring. The intensity of the monitoring should match the risk profile of the patient. Attention to cultural and educational barriers is important to prevent disparities in telehealth implementation. [ABSTRACT FROM AUTHOR]

Background: Unlike warfarin direct oral anticoagulants (DOACs) are administered in fixed doses, which raises concerns of its effectiveness on larger patients. Data from randomized trials are limited on the safety and efficacy of DOACs in morbidly obese individuals with atrial fibrillation (AF). Methods: We analyzed a cohort of obese (≥ 120 kg) and morbidly obese (BMI > 40 kg/m2) patients from the Veterans Health Administration system with AF who initiated apixaban, rivaroxaban, dabigatran, or warfarin between years 2012 and 2018. We used inverse probability of treatment weighting (IPTW) and Cox proportional hazards regression models to evaluate the relative hazard of death, myocardial infarction (MI), ischemic stroke, heart failure (HF), and bleeding events between oral anticoagulant (OAC) groups while censoring for medication cessation. Results: We identified 6052 obese patients on apixaban, 4233 on dabigatran, 4309 on rivaroxaban, and 13,417 on warfarin (mean age 66.7 years, 91% males, 80.4% whites). At baseline patients on apixaban had the lowest glomerular filtration rate and highest rates of previous stroke and MI compared to other OACs. Among patients with weight ≥ 120 kg and those with BMI > 40 kg/m2, all DOACs were associated with lower risk of any hemorrhage, hemorrhagic stroke, and gastrointestinal (GI) bleeding. Patients with BMI > 40 kg/m2 treated with DOACs had similar ischemic stroke risk with those on warfarin. Conclusions: In this large cohort of obese Veterans Health Administration system patients, the use of DOACs resulted in lower hemorrhagic complications than warfarin while maintaining efficacy on ischemic stroke prevention. [ABSTRACT FROM AUTHOR]

Accurate mean blood pressure determination is essential to prevent adverse events in patients with continuous-flow left ventricular assist devices (CFLVAD). We sought to evaluate the accuracy of noninvasive methods of blood pressure measurement compared with invasive intra-arterial recordings in patients with CFLVAD. Systematic electronic search was performed on four online databases (PubMed, Scopus, Embase, and Web of Knowledge) for the terms "Blood Pressure" AND ("Heart-Assist Devices" OR "Left ventricular Assist Devices"). Only studies that compared an intra-arterial and noninvasive blood pressure measurement were included. Electronic search of scientific literature identified 5968 articles. After deduplication, screening of titles and abstracts, full-text review, and excluding incorrect populations and comparator, a total of 12 studies with 502 participants were included, of those 402 participants who had intra-arterial blood pressure measurement. Doppler mean arterial blood pressure showed a very high correlation with mean intra-arterial blood pressure (r = 0.97, r = 0.87) in low pulsatility situations. When the pulsatility was not evaluated, the correlation was high moderate (r = 0.63, r = 0.741). In low pulsatility situations, the correlation was moderate to high moderate (r = 0.42 to r = 0.65). Oscillometer automatic blood pressure cuff showed a moderate to very high correlation with intra-arterial mean arterial blood pressure (r = 0.42, r = 0.86) but also could be low in the context of low pulsatility associated with inconsistent success in noninvasive measurement (r = 0.25). Studies correlating intra-arterial with noninvasive techniques were performed in the context of routine clinical care using fluid-filled catheters. The degree of correlation between both methods is at least moderate. [ABSTRACT FROM AUTHOR]

End-stage heart failure is a condition in which the up-regulation of the systemic and local renin-angiotensin-aldosterone system (RAAS) leads to end-organ damage and is largely irreversible despite optimal medication. Left ventricular assist devices (LVADs) can downregulate RAAS activation by unloading the left ventricle and increasing the cardiac output translating into a better end-organ perfusion improving survival. However, the absence of pulsatility brought about by continuous-flow devices may variably trigger RAAS activation depending on left ventricular (LV) intrinsic contractility, the design and speed of the pump device. Moreover, the concept of myocardial recovery is being tested in clinical trials and in this setting LVAD support combined with intense RAAS inhibition can promote recovery and ensure maintenance of LV function after explantation. Blood pressure control on LVAD recipients is key to avoiding complications as gastrointestinal bleeding, pump thrombosis and stroke. Furthermore, emerging data highlight the role of RAAS antagonists as prevention of arteriovenous malformations that lead to gastrointestinal bleeds. Future studies should focus on the role of angiotensin receptor inhibitors in preventing myocardial fibrosis in patients with LVADs and examine in greater details the target blood pressure for these patients. [ABSTRACT FROM AUTHOR]

Aims: This study aimed to evaluate the prescription frequency of potentially harmful prescription drugs as defined in current heart failure guidelines among elderly patients with a diagnosis of heart failure with reduced ejection fraction and their association with clinical outcomes. Methods and results: We used the Centers for Medicare & Medicaid Services data from a nationally representative 5% sample for the years 2014–2016 to identify patients admitted to acute care hospitals with a primary diagnosis of heart failure with reduced ejection fraction. The primary exposure was filling a prescription for a potentially harmful drug. Potentially harmful drug fills were treated as a time‐dependent covariate to examine their association on readmission and mortality. A total of 8993 patients met study criteria. Potentially harmful drugs were prescribed in 1077 (11.9%) patients within 90 days of discharge from the heart failure hospitalization. Non‐steroidal anti‐inflammatory agents were the most frequently prescribed potentially harmful drug (6.7%) followed by calcium channel blockers (4.7%), thiazolidinedione (0.59%), and select antiarrhythmic (0.33%). Factors independently associated with potentially harmful drug prescription were female gender, Hispanic ethnicity, severe obesity, among others. In the multivariable Cox model, the prescription of a potentially harmful drug was associated with an increased risk of readmission (hazard ratio 1.14; 95% confidence interval 1.05–1.23, P < 0.001). Among drug subgroups, only calcium channel blockers were associated with an increased risk of readmission (hazard ratio 1.225; 95% confidence interval 1.085–1.382, P = 0.0011). Conclusions: In elderly patients discharged with a primary diagnosis of heart failure with reduced ejection fraction on guideline‐directed medical therapy, prescription of a potentially harmful drug was frequent. Calcium channel blockers were associated with an increased risk of readmission. [ABSTRACT FROM AUTHOR]

Purpose of review: The goal of this review is to evaluate the interface between cardiogenic shock management and advanced heart failure therapy deployment. Recent findings: Cardiogenic shock is an emergency, and rapid recognition should be the first step in management. Although early revascularization and mechanical support promote heart recovery, persistent severe cardiac dysfunction leading to inability to wean hemodynamic support happens in a majority of patients. A shock team approach to cardiogenic shock management has resulted in improved patient outcomes. The timely intervention of the advanced heart failure team for evaluation and mitigation barriers for successful left ventricular assist device implantation or heart transplantation is critical to triage patients for successful exit strategies. Summary: An organized, protocolized, patient-centered team of team approach is key to maximizing chances of recognizing potential advanced heart failure therapy candidates. [ABSTRACT FROM AUTHOR]

We sought to evaluate the trends and outcomes of patients with left ventricular assist devices (LVADs) and inotropes at the time of listing for heart transplantation. Adults with an LVAD implanted and listed with 1A status were identified in the United Network for Organ Sharing (UNOS) registry between 2010 and 2017. Patients were grouped according to the presence or absence of inotropes at the time of listing and transplantation. A total of 2714 patients were included in the study including 664 patients on inotropes at the time of listing, 235 at the time of transplantation, and 118 on inotropes both at listing and at the time of transplantation. Patients on LVAD and inotropes at the time of listing were more frequently supported with a right ventricular assist device (RVAD) (P <.001), had higher risk of death in the waiting list (sub‐hazard ratio [SHR] = 1.48, 95% CI 1.14‐1.90, P =.002), and were less likely to be transplanted (SHR = 0.70, 95% CI 0.63‐0.78, P <.001) compared with those not on inotropes, after adjusting for described confounders. Approximately 1 in 10 LVAD recipients listed as status 1A are on inotropic therapy at the time of heart transplantation. Patients on LVAD and inotropes have worse outcomes in terms of survival and lower rates of transplantation. [ABSTRACT FROM AUTHOR]

Aims: Adequate health insurance coverage is necessary for heart transplantation (HT) candidates. Prior studies have suggested inferior outcomes post HT with public health insurance. We sought to evaluate the effects of insurance type on transplantation rates, listing status and mortality prior to HT. Methods and results: Patients ≥18 years old with a left ventricular assist device implanted and listed with 1A status were identified in the United Network for Organ Sharing registry between January 2010 and December 2017, with follow‐up through March 2018. Patients were grouped based on the type of insurance private/self‐pay (PV), Medicare (MC), and Medicaid (MA) at the time of listing. We conducted multivariable competing risks regression analysis on listing status and mortality on the waiting list, stratified by insurance type at the time of listing. We identified 2604 patients listed in status 1A (PV: 51.4%, MC: 32.1%, and MA: 16.5%). MA patients were younger (43.5 vs. 56.4 for MC vs. 51.5 for PV, P < 0.001) and less frequently White (P < 0.001). The cumulative incidence of HT did not differ among the three insurance types (PV: 74.8%, MC 76.3%, and MA 71.1%, P = 0.14). The cumulative mortality on the waiting list prior to HT was not different among groups (PV: 29.3%, MC 26.3%, and MA 21.8%, P = 0.94). Μore patients with MA were removed from the list because of improvement of their condition (MA 40.3% vs. MC 28.3% and PV 32.8%). Conclusions: We did not detect any disparities in listing status and mortality among different insurance types. [ABSTRACT FROM AUTHOR]

Background: We evaluated adherence to dosing criteria for patients with atrial fibrillation (AF) taking dabigatran or rivaroxaban and the impact of off-label dosing on thromboembolic and bleeding risk.Methods: We used data for a retrospective cohort from a large U.S. health plan for Medicare beneficiaries age > =65 years with AF who initiated dabigatran or rivaroxaban during 2010-2016. Stroke and major bleeding were quantified in patients who were eligible for low dose but received standard dose, and in patients who were eligible for standard dose but received low dose.Results: We identified 8035 and 19,712 patients who initiated dabigatran or rivaroxaban, respectively. Overall, 1401 (17.4%) and 7820 (39.7%) patients who received dabigatran and rivaroxaban met criteria for low dose, respectively. Of those, 959 (68.5%) and 3904 (49.9%) received standard dose. In contrast, 1013 (15.3%) and 2551 (21.5%) of patients eligible for standard dose dabigatran and rivaroxaban received low dose. Mean follow-up for patients eligible for low and standard dose dabigatran and rivaroxaban were 13.9, 15.1, 10.1, and 12.3 months, respectively. In unadjusted analyses, patients eligible for low or standard dose dabigatran and rivaroxaban but receiving off-label dose, had no differences in the rates of ischemic stroke. Among patients who met criteria for standard dose direct oral anticoagulants (DOAC), use of low dose was associated with significantly higher risk of any major bleeding (Dabigatran: HR = 1.44; 95% CI 1.14-1.8, P = 0.002, Rivaroxaban HR 1.34, 95% CI 1.11-1.6, P = 0.002) and gastrointestinal bleeding (Dabigatran: HR = 1.48; 95% CI 1.08-2, P = 0.016). In patients who met criteria for low dose DOACs, there was lower risk of major bleeding (Dabigatran: HR = 0.59; 95% CI 0.43-0.8, P < 0.001), gastrointestinal (Rivaroxaban: HR 0.79; 95% CI 0.64-0.98, P = 0.03) and intracranial bleeding (Dabigatran: HR = 0.33; 95% CI 0.12-0.9, P = 0.001) with standard dosing. After propensity matching, use of off-label doses was not associated with stroke, major, gastrointestinal or intracranial bleeding for either dabigatran or rivaroxaban.Conclusions: While a significant number of patients receive higher or lower dose of dabigatran and rivaroxaban than recommended, we found no evidence of significant impact on thromboembolic or hemorrhagic outcomes. [ABSTRACT FROM AUTHOR]

Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome characterized by symptoms and sings of heart failure with elevated left ventricular filling pressures at rest or during exercise. It is the most common type of heart failure in the elderly and its prevalence increases with age and is higher in females at any given age. HFpEF is frequently accompanied of comorbid conditions such as diabetes mellitus, obesity, atrial fibrillation and renal dysfunction. The diagnosis relies in the integration of clinical information, laboratory data and interpretation of cardiac imaging and hemodynamic findings at rest and during exercise. Conditions that have a specific treatment such as coronary artery disease, valvular disease, cardiac amyloidosis and constrictive pericarditis should be considered and evaluated as appropriate. Aggressive management of comorbidities, optimization of blood pressure control and volume status using diuretics as needed are among the current treatment recommendations. There are no specific therapies that have shown to decrease mortality in HFpEF. In symptomatic patients with history of hospital admission for decompensated heart failure, the implantation of a wireless pulmonary artery pressure monitor should be considered. Finally, given the high mortality of this condition, goals of care discussion should be initiated early and involvement of palliative care medicine should be considered. [ABSTRACT FROM AUTHOR]

The impact of cardiac resynchronization therapy (CRT) on clinical outcome in patients with a continuous-flow left ventricular assist device (LVAD) is currently not well understood. We conducted a systematic literature review and meta-analysis with an intention to summarize all published clinical evidence. We searched MEDLINE and EMBASE databases through March 2018 for studies that compared the outcomes in patients with LVAD and CRT. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated using a random-effects model, inverse variance method. The between-study heterogeneity was assessed using the Q statistic and I2. A total of seven studies that included 1157 (575 CRT; 582 non-CRT) patients were identified. Our meta-analysis did not demonstrate a significant difference in the risk of mortality (pooled OR = 1.21, 95% CI 0.90-1.63, P = 0.21), ventricular arrhythmia incidence (pooled OR = 1.36, 95% CI 0.99-1.86, P = 0.06), hospitalization (pooled OR = 1.36, 95% CI 0.59-3.14, P = 0.48), or implantable cardioverter defibrillator therapies (pooled OR = 1.08, 95% CI 0.51-2.30, P = 0.84) among the CRT group compared with the non-CRT group. There was high heterogeneity with an I2 of 75% for ICD therapies. Among LVAD patients, CRT combined did not significantly affect mortality, re-hospitalization, ventricular arrhythmia incidence, and ICD therapies. [ABSTRACT FROM AUTHOR]

Approximately 50% of heart transplant programs currently employ a strategy of induction therapy (IT) with either interleukin-2 receptor antagonists (IL2RA) or polyclonal anti-thymocyte antibodies (ATG) during the early postoperative period. However, the overall utility of such therapy is uncertain and data comparing induction protocols are limited. The authors searched PubMed, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov through January 2018 for randomized controlled trials (RCTs) or observational controlled studies of IT vs no IT and IL2RA vs ATG. Inverse variance fixed effects models with odds ratio (OR) as the effect measure were used for primary analyses. Main outcomes include moderate and severe rejection, all-cause mortality, infection, and cancer. The authors' search retrieved 2449 studies, of which 11 met criteria for inclusion (8 RCTs and 3 observational case-control studies). Quality of evidence for RCTs was moderate to high. Overall, patients receiving IT had similar risk of moderate-to-severe rejection, all-cause death, infection, and cancer with patients who did not receive IT. The use of IL2RA was associated with significantly higher risk of moderate-to-severe rejection than ATG (OR 3.4; 95% CI 1.4 to 8.1), but similar risk of death, infections, and cancer. The use of IT was not associated with any benefits or harms compared with no IT. Moderate-to-severe rejection may be reduced by ATG compared with IL2RA. [ABSTRACT FROM AUTHOR]

We sought to determine the relation between myocardial extracellular volume (ECV), left ventricular (LV) diastolic function, and exercise tolerance in patients with hypertrophic cardiomyopathy (HCM). Forty five HCM patients with an ejection fraction >50% and no previous septal reduction therapy underwent imaging by CMR and transthoracic echocardiography. CMR was used to quantify LV volumes, mass, EF, LA volumes, scar burden, pre and post contrast T1 relaxation times and ECV. Echocardiography was used to measure outflow tract gradients, mitral inflow and annular velocities, circumferential strain, systolic, early and late diastolic strain rates. Exercise duration and peak oxygen consumption were noted. HCM patients had increased native T1 relaxation time and ECV vs. controls [ECV controls: 24.7 (23.2-26.4) vs. HCM: 26.8 (24.6-31.3)%, P = 0.014]. Both parameters were significantly associated with LV diastolic dysfunction, circumferential strain, diastolic strain rate and peak oxygen consumption (r = -0.73, P < 0.001). Compared to controls, HCM patients have significantly longer native T1 relaxation time and higher ECV. These structural changes lead to worse LV global and segmental diastolic function and in turn reduced exercise tolerance. [ABSTRACT FROM AUTHOR]

Aim To determine the prevalence of in-hospital nonsteroidal antiinflammatory drug (NSAID) exposure and associated outcomes in patients admitted with a primary diagnosis of heart failure. Methods We performed a propensity-matched cohort analysis of patients admitted to Houston Methodist Hospital System with a primary diagnosis of heart failure according to the International Classification of Diseases-9-Clinical Modification (ICD-9-CM) from January 1, 2011 to December 31, 2014. Results Of the 9742 patients admitted with a primary diagnosis of heart failure, 384 patients (3.9%) were exposed to NSAID. After applying propensity scores we matched 305 NSAID exposed with 915 unexposed patients. Patients with in-hospital NSAID exposure had a longer length of stay (7.0±8.8 days vs 6.1±8.5; P=.003) and increased prevalence of worsening renal function (34.4% vs 27.9%; P=.030). There were not statically significant differences in in-hospital mortality rate or 30-day all-cause readmission rate. Conclusion Exposure to NSAID in patients admitted with a primary diagnosis of heart failure was low but was associated with adverse outcomes including longer length of stay and higher prevalence or worsening renal function. [ABSTRACT FROM AUTHOR]

BACKGROUND: Non-steroidal anti-inflammatory drugs are considered potentially harmful for patients with heart failure. OBJECTIVE: To determine the prevalence of in-hospital NSAID use their type, associated diagnosis and impact in clinical outcomes among patients with a diagnosis of heart failure. METHODS: The University Health System Consortium Database was used to identify all first hospitalizations with an International Classification of Diseases-9 discharge diagnosis code of systolic heart failure as the primary diagnosis between January 1, 2011 and December 31st 2014. RESULTS: Among 65,902 patients admitted for a primary diagnosis of SHF, 2675 (4.1%) were exposed to NSAID. The most frequent NSAID used was ibuprofen (51.63%), followed by ketorolac (29.38%) naproxen (8.07%) celecoxib (5.61%) and others. On multivariable analyses the length of stay of patients exposed to NSAID was longer compared to non-exposed (OR: 4.67, p < 0.001, 95% CI 4.10-5.25), but differences in mortality were not statistically different (OR: 0.90, p = 0.476, 95% CI 0.69-1.19). CONCLUSION: The use of NSAID in patients admitted with a primary diagnosis of systolic heart failure was low but was associated with longer length of stay. Further studies are needed to understand the impact of NSAID use in this patient population. [ABSTRACT FROM AUTHOR]

Exercise limitation is the hallmark of heart failure, and an increasing degree of intolerance is associated with poor prognosis. Objective evaluation of functional class (e.g., cardiopulmonary exercise testing) is essential for adequate prognostication in patients with advanced heart failure and for implementing an appropriate exercise training program. A graded exercise program has been shown to be beneficial in patients with heart failure and has become an essential component of comprehensive cardiac rehabilitation in these patients. An exercise program tailored to the patient's preferences, possibilities, and physiologic reserve has the greatest chance of being successful. Despite being safe, effective, and a guideline-recommended treatment to improve quality of life, exercise training remains grossly underutilized. Patient, physician, insurance and practice barriers need to be addressed to improve this quality gap. [ABSTRACT FROM AUTHOR]

BACKGROUND: Adverse Drug Reactions (ADR) are a major cause of morbidity and mortality worldwide. In spite of this, ADR are largely underreported and unrecognized. PURPOSE: Identify and characterize ADR related admissions to our internal medicine ward using a proactive multidisciplinary pharmacovigilance approach. METHODS: Within 24 hrs of admission 1045 patients admitted to the Internal Medicine Ward between August 2010 and February 2012 were screened for possible or probable ADR related admissions. RESULTS: Probable ADR accounted for 112 of 1045 admissions (10.7%, 95% Confidence Interval [CI]: 8.8-12.6%), of which only 16 (14.3%) were classified as unavoidable. NSAIDs were the drug group more commonly implicated in probable ADR-related admissions (17.0%), followed by antiplatelets (16.1%). In-hospital mortality of patients admitted due to probable ADR was 8.0% (95% CI: 2.9-13.1%). During this study period, 6% of internal medicine ward and 4% of critical care unit beds were occupied by patients with probable ADR. The estimated cost of care of these patients was 641,000 US dollars (USD). CONCLUSION: ADR are a frequent reason for admission to an Internal Medicine Ward in Argentina. The culprit drugs and interactions are similar to those reported in the literature. The cost is substantial and most of the ADR are potentially avoidable. [ABSTRACT FROM AUTHOR]

Background: Cell therapy (CTh) is a promising novel therapy for myocardial infarction (MI) and ischemic cardiomyopathy (iCMP). Recognizing adverse events (AE) is important for safety evaluation, harm prevention and may aid in the design of future trials. Objective: To define the prevalence of periprocedural AE in CTh trials in MI and iCMP. Methods: A literature search was conducted using the MEDLINE database from January 1990 to October 2010. Controlled clinical trials that compared CTh with standard treatment in the setting of MI and/or iCMP were selected. AE related to CTh were analyzed. Results: A total of 2,472 patients from 35 trials were included. There were 26 trials including 1,796 patients that used CTh in MI and 9 trials including 676 patients that used CTh in iCMP. Periprocedural arrhythmia monitoring protocols were heterogeneous and follow-up was short in most of the trials. In MI trials, the incidence of periprocedural adverse events (AE) related to intracoronary cell transplantation was 7.5 % (95 % CI 6.04-8.96 %). AE related to granulocyte colony-stimulating factor (GCS-F) used for cell mobilization for peripheral apheresis was 16 % (95 % CI 9.44-22.56 %). During intracoronary transplantation in iCMP, the incidence of periprocedural AE incidence was 2.6 % (95 % CI 0.53-4.67 %). There were no AE reported during transepicardial transplantation and AE were rare during transendocardial transplantation. Conclusions: The majority of periprocedural AE in CTh trials in MI occurred during intracoronary transplantation and GCS-F administration. In iCMP, periprocedural AE were uncommon. Avoiding intracoronary route for CTh implantation may decrease the burden of periprocedural AE. Standardization of AE definition in CTh trials is needed. [ABSTRACT FROM AUTHOR]

Leflunomide, a disease-modifying antirheumatic drug, has been shown to be effective in the management of rheumatoid arthritis (RA). Among other side effects, systemic hypertension has been described, and also a case of possible pulmonary hypertension (PH) has been reported. Symptomatic PH in RA is rare. We present a 28-year-old woman with a history of RA who consulted our hospital because of severe symptomatic pulmonary hypertension. Two years before admission, she was started on leflunomide. Due to previous evidence of the association of leflunomide with pulmonary hypertension, the drug was stopped. The patient became asymptomatic with normal pulmonary arterial pressure within a year. Given the poor prognosis of idiopathic pulmonary arterial hypertension, the recognition of potentially reversible causes is crucial. Until further evidence is available in a patient who develops pulmonary arterial hypertension, stopping leflunomide should be considered. [ABSTRACT FROM AUTHOR]

Background: In patients with idiopathic dilated cardiomyopathy (IDCM), the myocardial blood flow is markedly depressed. The presence of alterations in the number and length of the coronary microcirculation has not been explored. Methods: In explanted hearts of 6 patients with IDCM and in 6 normal control hearts, the arteriolar length density and capillary numerical density were determined in sections stained with orcein (vessels 50-200 μm in diameter), for smooth muscle actin (vessels 6-50 μm in diameter) and CD34 (capillaries). Results: No difference with normal hearts was observed in capillary numerical density and in length density of vessels above 50 μm in diameter. In IDCM, more than 50% of arterioles below 50 μm in diameter displayed an incomplete smooth muscle wall, and length density, especially for arterioles between 6 and 20 μm in diameter, was significantly lower (42.84 ± 8.51 mm/mm3) than in controls (75.34 ± 3.05 mm/mm3, p = 0.001). Conclusions: In IDCM, arterioles below 50 μm in diameter display an incomplete smooth muscle wall and a significant decrease in length density. These observations provide an anatomical basis for a decreased coronary flow reserve in IDCM. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]