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Background: Observational data suggest that the subset of patients with heart failure related CS (HF-CS) now predominate critical care admissions for CS. There are no dedicated HF-CS randomised control trials completed to date which reliably inform clinical practice or clinical guidelines. We sought to identify aspects of HF-CS care where both consensus and uncertainty may exist to guide clinical practice and future clinical trial design, with a specific focus on HF-CS due to acute decompensated chronic HF., Methods: A 16-person multi-disciplinary panel comprising of international experts was assembled. A modified RAND/University of California, Los Angeles, appropriateness methodology was used. A survey comprising of 34 statements was completed. Participants anonymously rated the appropriateness of each statement on a scale of 1 to 9 (1-3 as inappropriate, 4-6 as uncertain and as 7-9 appropriate)., Results: Of the 34 statements, 20 were rated as appropriate and 14 were rated as inappropriate. Uncertainty existed across all three domains: the initial assessment and management of HF-CS; escalation to temporary Mechanical Circulatory Support (tMCS); and weaning from tMCS in HF-CS. Significant disagreement between experts (deemed present when the disagreement index exceeded 1) was only identified when deliberating the utility of thoracic ultrasound in the immediate management of HF-CS., Conclusion: This study has highlighted several areas of practice where large-scale prospective registries and clinical trials in the HF-CS population are urgently needed to reliably inform clinical practice and the synthesis of future societal HF-CS guidelines., (© 2024. The Author(s).)

Cardiogenic shock (CS) is a time-sensitive and hemodynamically complex syndrome with a broad spectrum of etiologies and clinical presentations. Despite contemporary therapies, CS continues to maintain high morbidity and mortality ranging from 35 to 50%. More recently, burgeoning observational research in this field aimed at enhancing the early recognition and characterization of the shock state through standardized team-based protocols, comprehensive hemodynamic profiling, and tailored and selective utilization of temporary mechanical circulatory support devices has been associated with improved outcomes. In this narrative review, we discuss the pathophysiology of CS, novel phenotypes, evolving definitions and staging systems, currently available pharmacologic and device-based therapies, standardized, team-based management protocols, and regionalized systems-of-care aimed at improving shock outcomes. We also explore opportunities for fertile investigation through randomized and non-randomized studies to address the prevailing knowledge gaps that will be critical to improving long-term outcomes., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The handling editor LC declared a past co-authorship with the authors CR, SD, MP., (© 2024 Mehta, Vavilin, Nguyen, Batchelor, Blumer, Cilia, Dewanjee, Desai, Desai, Flanagan, Isseh, Kennedy, Klein, Moukhachen, Psotka, Raja, Rosner, Shah, Tang, Truesdell, Tehrani and Sinha.)

Ischemic heart disease is a crucial issue during pregnancy. The term is composed of both preexisting conditions and acute coronary syndrome in pregnancy, including pregnancy-associated myocardial infarction, which can have a significant effect on maternal and fetal outcomes. This review provides a complete guide to managing ischemic heart disease in pregnant women, emphasizing the importance of multidisciplinary care and individualized treatment strategies. Cardiovascular disease, particularly ischemic heart disease, is now the leading cause of maternal mortality worldwide. Pregnancy introduces unique physiological changes that increase the risk of acute myocardial infarction, with pregnancy-associated myocardial infarction cases often associated with factors, such as advanced maternal age, chronic hypertension, and preexisting cardiovascular conditions. This review distinguishes between preexisting ischemic heart disease and pregnancy-associated myocardial infarction. It will emphasize the various etiologies of pregnancy-associated myocardial infarction, including coronary atherosclerosis and plaque rupture presenting as ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, and other nonatherosclerotic causes, including spontaneous coronary artery dissection, vasospasm, and embolism. Our study discusses the practical management of ischemic heart disease in pregnancy, with a focus on preconception counseling, risk assessment, and tailored antenatal planning for women with preexisting ischemic heart disease. Moreover, this document focuses on the challenges of diagnosing cardiovascular disease, especially when presented with nonclassical risk factors and presentation. It provides insight into the appropriate diagnostic testing methods, such as electrocardiogram, cardiac biomarkers, and echocardiography. In addition, the review covers various treatment strategies, from medical management to more invasive procedures, including coronary angiography, percutaneous coronary intervention, and coronary artery bypass graft. Special attention is given to medication safety during pregnancy, including anticoagulation, beta-blockers, and antiplatelet agents. The complexities of delivery planning in women with ischemic heart disease are discussed, advocating for a multidisciplinary team-based approach and careful consideration of the timing and mode of delivery. Furthermore, the roles of breastfeeding and postpartum care are explored, emphasizing the long-term benefits and the suitability of various medications during lactation. Lastly, this review provides crucial insights into the management of ischemic heart disease in pregnancy, stressing the need for heightened awareness, prompt diagnosis, and tailored management to optimize maternal and fetal health outcomes., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Cardiovascular disease (CVD) is the leading cause of death worldwide and accounts for roughly 1 in 5 deaths in the United States. Women in particular face significant disparities in their cardiovascular care when compared to men, both in the diagnosis and treatment of CVD. Sex differences exist in the prevalence and effect of cardiovascular risk factors. For example, women with history of traditional cardiovascular risk factors including hypertension, tobacco use, and diabetes carry a higher risk of major cardiovascular events and mortality when compared to men. These discrepancies in terms of the relative risk of CVD when traditional risk factors are present appear to explain some, but not all, of the observed differences among men and women. Sex-specific cardiovascular disease research-from identification, risk stratification, and treatment-has received increasing recognition in recent years, highlighting the current underestimated association between CVD and a woman's obstetric and reproductive history. In this comprehensive review, sex-specific risk factors unique to women including adverse pregnancy outcomes (APO), such as hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus, preterm delivery, and newborn size for gestational age, as well as premature menarche, menopause and vasomotor symptoms, polycystic ovarian syndrome (PCOS), and infertility will be discussed in full detail and their association with CVD risk. Additional entities including spontaneous coronary artery dissection (SCAD), coronary microvascular disease (CMD), systemic autoimmune disorders, and mental and behavioral health will also be discussed in terms of their prevalence among women and their association with CVD. In this comprehensive review, we will also provide clinicians with a guide to address current knowledge gaps including implementation of a sex-specific patient questionnaire to allow for appropriate risk assessment, stratification, and prevention of CVD in women., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Nguyen, Hurwitz, Sullivan, Saad, Kennedy and Sharma.)

Heart failure (HF) remains a major cause of morbidity and mortality worldwide. Major advancements in optimal guideline-directed medical therapy, including novel pharmacological agents, are now available for the treatment of chronic HF including HF with reduced ejection fraction and HF with preserved ejection fraction. Despite these efforts, there are several limitations of medical therapy including but not limited to: delays in implementation and/or initiation; inability to achieve target dosing; tolerability; adherence; and recurrent and chronic costs of care. A significant proportion of patients remain symptomatic with poor HF-related outcomes including rehospitalization, progression of disease, and mortality. Driven by these unmet clinical needs, there has been a significant growth of innovative device-based interventions across all HF phenotypes over the past several decades. This state-of-the-art review will summarize the current landscape of guideline-directed medical therapy for chronic HF, discuss its limitations including barriers to implementation, and review device-based therapies which have established efficacy or demonstrated promise in the management of chronic HF., (© 2023 The Author(s).)

Introduction: Pulmonary hypertension (PH) is prevalent in those with end-stage kidney disease (ESKD) and poses a barrier to kidney transplant due to its association with poor outcomes. Studies examining these adverse outcomes are limited and often utilize echocardiographic measurements of pulmonary artery systolic pressure (PASP) instead of the gold standard right heart catheterization (RHC). We hypothesized that in ESKD patients deemed ineligible for kidney transplant because of an echocardiographic diagnosis of PH the predominant cause of PH is hypervolemia and is potentially reversible., Methods: We conducted a prospective study of 16 patients with ESKD who were denied transplant candidacy. Prior echocardiograms and RHCs were reviewed for confirmation of PH. Patients were admitted for daily sessions of ultrafiltration for volume removal and repeat RHCs were performed following intervention. RHC parameters and body weight were compared before and after intervention. Statistical analysis was performed using PRISM GraphPad software. A p-value <.05 was considered statistically significant., Results: Following intervention, the mean pulmonary artery pressure (mPAP) and pulmonary arterial wedge pressure decreased from 45.0 ± 3.06 to 29.1 ± 7.77 mmHg (p < .0001) and 22.2 ± 5.06 to 13.1 ± 7.25 mmHg (p = .003), respectively. The pulmonary vascular resistance decreased from 4.73 ± 1.99 to 4.28 ± 2.07 WU (p = .30). Eleven patients from the initial cohort underwent successful kidney transplantation post-intervention with 100% survival at 1-year., Conclusions: In ESKD patients, diagnoses of PH made by echocardiography may be largely due to hypervolemia and may be optimized using an intensive ultrafiltration strategy to restore transplant candidacy., (© 2022 The Authors. Clinical Transplantation published by John Wiley & Sons Ltd.)

Purpose of Review: Left heart disease is the most common cause of pulmonary hypertension. This review summarizes the current care of patients with pulmonary hypertension caused by left heart disease (PH-LHD) and discusses recent and active clinical trials in this patient population., Recent Findings: The primary focus of interventions aimed at treating PH-LHD address the treatment of left heart disease. Significant advancements in the treatment of heart failure with preserved ejection fraction (HFpEF), a frequent cause of PH-LHD, are supported in the current literature. Patients with residual pulmonary hypertension despite optimal treatment of left heart disease have poor outcomes. Yet, interventions targeting the pulmonary vasculature in PH-LHD patients have not demonstrated significant benefits in studies to date. Current work focuses on differentiating isolated postcapillary pulmonary hypertension (IpcPH) from combined precapillary and postcapillary pulmonary hypertension (CpcPH) in a clinically consistent manner. It is hopeful that thorough phenotyping of PH-LHD patients will translate into effective treatment strategies addressing pulmonary vascular disease., Summary: Referral to centers of excellence, considerations for enrollment in clinical trials, and evaluation for transplant is recommended for patients with residual pulmonary hypertension despite optimal treatment of left heart disease, particularly those with CpcPH., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Venoarterial extracorporeal membrane oxygenation (ECMO) has been used to treat acute massive pulmonary embolism (PE) patients. However, the incremental benefit of ECMO to standard therapy remains unclear. Our meta-analysis objective is to compare in-hospital mortality in patients treated for acute massive PE with and without ECMO. The National Library of Medicine MEDLINE (USA), Web of Science, and PubMed databases from inception through October 2020 were searched. Screening identified 1002 published articles. Eleven eligible studies were identified, and 791 patients with acute massive PE were included, of whom 270 received ECMO and 521 did not. In-hospital mortality was not significantly different between patients treated with vs. without ECMO (OR = 1.24 [95% CI, 0.63-2.44], p = 0.54). However, these findings were limited by significant study heterogeneity. Additional research will be needed to clarify the role of ECMO in massive PE treatment. In-hospital mortality for patients with acute massive pulmonary embolism was not significantly different (OR of 1.24, p = 0.54) between those treated with and without venoarterial ECMO., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Pulmonary artery proportional pulse pressure (PAPP) was recently shown to have prognostic value in heart failure (HF) with reduced ejection fraction (HFrEF) and pulmonary hypertension. We tested the hypothesis that PAPP would be predictive of adverse outcomes in patients with implantable pulmonary artery pressure monitor (CardioMEMS™ HF System, St. Jude Medical [now Abbott], Atlanta, GA, USA)., Methods: Survival analysis with Cox proportional hazards regression was used to evaluate all-cause deaths and HF hospitalisation (HFH) in CHAMPION trial 1 patients who received treatment with the CardioMEMS device based on the PAPP., Results: Among 550 randomised patients, 274 had PAPP ≤ the median value of 0.583 while 276 had PAPP>0.583. Patients with PAPP≤0.583 (versus PAPP>0.583) had an increased risk of HFH (HR 1.40, 95% CI 1.16-1.68, p=0.0004) and experienced a significant 46% reduction in annualised risk of death with CardioMEMS treatment (HR 0.54, 95% CI 0.31-0.92) during 2-3 years of follow-up. This survival benefit was attributable to the treatment benefit in patients with HFrEF and PAPP≤0.583 (HR 0.50, 95% CI 0.28-0.90, p<0.05). Patients with PAPP>0.583 or HF with preserved EF (HFpEF) had no significant survival benefit with treatment (p>0.05)., Conclusion: Lower PAPP in HFrEF patients with CardioMEMS constitutes a higher mortality risk status. More studies are needed to understand clinical applications of PAPP in implantable pulmonary artery pressure monitors., (Copyright © 2021 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: As the population becomes increasingly obese, so does the pool of potential organ donors. We sought to investigate the impact of donors with body mass index ≥40 (severe obesity) on heart transplant outcomes., Methods: Single-organ first-time adult heart transplants from 2003 to 2017 were evaluated from the United Network for Organ Sharing database and stratified by donor severe obesity status (body mass index ≥40). Demographics were compared, and univariate and risk-adjusted analyses evaluated the relationship between severe obesity and short-term outcomes and long-term mortality. Further analysis evaluated the prevalence of severe obesity within the pool of organ donation candidates., Results: A total of 26 532 transplants were evaluated, of which 939 (3.5%) had donors with body mass index ≥40, with prevalence increasing over time (2.2% in 2003, 5.3% in 2017). Severely obese donors more likely had diabetes mellitus (10.4% versus 3.1%, P <0.01) and hypertension (33.3% versus 14.8%, P <0.01), and 67.4% were size mismatched (donor weight >130% of recipient). Short-term outcomes were similar, including 1-year survival (10.6% versus 10.7%), with no significant difference in unadjusted and risk-adjusted long-term survival (log-rank P =0.67, hazard ratio, 0.928, P =0.30). Organ donation candidates also exhibited an increase in severe obesity over time, from 3.5% to 6.8%, with a lower proportion of hearts from severely obese donors being transplanted (19.5% versus 31.6%, P <0.01)., Conclusions: Donor severe obesity was not associated with adverse post-transplant outcomes. Increased evaluation of hearts from obese donors, even those with body mass index ≥40, has the potential to expand the critically low donor pool.

Background: Acute pulmonary embolism remains a significant cause of mortality and morbidity worldwide. Benefit of recently developed multidisciplinary PE response teams (PERT) with higher utilization of advanced therapies has not been established., Methods: To evaluate patient-centered outcomes and cost-effectiveness of a multidisciplinary PERT we performed a retrospective analysis of 554 patients with acute PE at the university of Virginia between July 2014 and June 2015 (pre-PERT era) and between April 2017 through October 2018 (PERT era). Six-month survival, hospital length-of-stay (LOS), type of PE therapy, and in-hospital bleeding were assessed upon collected data., Results: 317 consecutive patients were treated for acute PE during an 18-month period following institution of a multidisciplinary PE program; for 120 patients PERT was activated (PA), the remaining 197 patients with acute PE were considered as a separate, contemporary group (NPA). The historical, comparator cohort (PP) was composed of 237 patients. These 3 groups were similar in terms of baseline demographics, comorbidities and risk, as assessed by the Pulmonary Embolism Severity Index (PESI). Patients in the historical cohort demonstrated worsened survival when compared with patients treated during the PERT era. During the PERT era no statistically significant difference in survival was observed in the PA group when compared to the NPA group despite significantly higher severity of illness among PA patients. Hospital LOS was not different in the PA group when compared to either the NPA or PP group. Hospital costs did not differ among the 3 cohorts. 30-day re-admission rates were significantly lower during the PERT era. Rates of advanced therapies were significantly higher during the PERT era (9.1% vs. 2%) and were concentrated in the PA group (21.7% vs. 1.5%) without any significant rise in in-hospital bleeding complications., Conclusions: At our institution, all-cause mortality in patients with acute PE has significantly and durably decreased with the adoption of a PERT program without incurring additional hospital costs or protracting hospital LOS. Our data suggest that the adoption of a multidisciplinary approach at some institutions may provide benefit to select patients with acute PE.

Background: Right ventricular failure (RVF) portends poor outcomes after left ventricular assist device (LVAD) implantation. Although numerous RVF predictive models have been developed, there are few independent comparative analyses of these risk models., Methods and Results: RVF was defined as use of inotropes for >14 days, inhaled pulmonary vasodilators for >48 hours or unplanned right ventricular mechanical support postoperatively during the index hospitalization. Risk models were evaluated for the primary outcome of RVF by means of logistic regression and receiver operating characteristic curves. Among 93 LVAD patients with complete data from 2011 to 2016, the Michigan RVF score (C = 0.74 [95% CI 0.61-0.87]; P = .0004) was the only risk model to demonstrate significant discrimination for RVF, compared with newer risk scores (Utah, Pitt, EuroMACS). Among individual hemodynamic/echocardiographic metrics, preoperative right ventricular dysfunction (C = 0.72 [95% CI 0.58-0.85]; P = .0022) also demonstrated significant discrimination of RVF. The Michigan RVF score was also the best predictor of in-hospital mortality (C = 0.67 [95% CI 0.52-0.83]; P = .0319) and 3-year survival (Kaplan-Meier log-rank 0.0135)., Conclusions: In external validation analysis, the more established Michigan RVF score-which emphasizes preoperative hemodynamic instability and target end-organ dysfunction-performed best, albeit modestly, in predicting RVF and demonstrated association with in-hospital and long-term mortality., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Pulmonary arterial hypertension (PAH) is characterised by remodelling of the pulmonary vasculature leading to right ventricular (RV) failure. The failing RV, through interventricular uncoupling, deleteriously impacts the left ventricle and overall cardiac efficiency. We hypothesised that the ratio of the pulmonary artery pulse pressure to the systemic pulse pressure ("pulmonary-systemic pulse pressure ratio", or PS-PPR) would be associated with mortality in PAH., Methods: We conducted a retrospective analysis of 262 patients in the National Institute of Health Primary Pulmonary Hypertension Registry (NIH-PPH). We evaluated the association between the PS-PPR and mortality after adjustment for the Pulmonary Hypertension Connection (PHC) risk equation., Results: Among 262 patients (mean age 37.5±15.8years, 62.2% female), median PS-PPR was 1.04 (IQR 0.79-1.30). In the Cox proportional hazards regression model, each one unit increase in the PS-PPR was associated with more than a two-fold increase in mortality during follow-up (HR 2.06, 95% CI 1.40-3.02, p=0.0002), and this association of PS-PPR with mortality remained significant in the multivariable Cox model adjusted for the PHC risk equation, mean pulmonary artery pressure, and body mass index (BMI) (adjusted HR 1.81, 95% CI 1.13-2.88, p=0.01). Furthermore, PS-PPR in the upper quartile (>1.30) versus quartiles 1-3 was associated with a 68% increase in mortality after adjustment for these same covariates (adjusted HR 1.68, 95% CI 1.13-2.50, p=0.01)., Conclusions: Pulmonary-systemic pulse pressure ratio, a marker of biventricular efficiency, is associated with survival in PAH even after adjustment for the PHC risk equation. Further studies are needed on the wider applications of PS-PPR in PAH patients., (Copyright © 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Pulmonary artery (PA) pulsitility index (PAPi) is a novel haemodynamic index shown to predict right ventricular failure in acute inferior myocardial infarction and post left ventricular assist device surgery. We hypothesised that PAPi calculated as [PA systolic pressure - PA diastolic pressure]/right atrial pressure (RAP) would be associated with mortality in the National Institutes of Health Registry for Primary Pulmonary Hypertension (NIH-RPPH)., Methods: The impact of PAPi, the Pulmonary Hypertension Connection (PHC) risk score, right ventricular stroke work, pulmonary artery capacitance (PAC), other haemodynamic indices, and demographic characteristics was evaluated in 272 NIH-RPPH patients using multivariable Cox proportional hazards (CPH) regression and receiver operating characteristic (ROC) analysis., Results: In the 272 patients (median age 37.7+/-15.9years, 63% female), the median PAPi was 5.8 (IQR 3.7-9.2). During 5years of follow-up, 51.8% of the patients died. Survival was markedly lower (32.8% during the first 3years) in PAPi quartile 1 compared with the remaining patients (58.5% over 3years in quartiles 2-4; p<0.0001). The best multivariable CPH survival model included PAPi, the PHC-Risk score, PAC, and body mass index (BMI). In this model, the adjusted hazard ratio for death with increasing PAPi was 0.946 (95% CI 0.905-0.989). The independent ROC areas for 5-year survival based on bivariable logistic regression for PAPi, BMI, PHC Risk, and PAC were 0.63, 0.62, 0.64, and 0.65, respectively (p<0.01). The ROC area for 5-year survival for the multivariable logistic model with all four covariates was 0.77 (p<0.0001)., Conclusions: Pulmonary artery pulsatility index was independently associated with survival in PAH, highlighting the utility of PAPi in combination with other key measures for risk stratification in this population., (Copyright © 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

A retrospective cohort study was performed of the Hospital-to-Home (H2H) program, a rapid clinic follow-up program for patients with recent heart failure (HF) admissions at the University of Virginia Health System. There were 6761 hospitalizations among 4685 patients (age 67.5 ± 14.2 years, 43.9% female), and 759 had H2H follow-up. Thirty day mortality after the initial HF hospitalization was lower in H2H patients (1.84% vs 3.13%; P = .049), and this difference remained significant after adjustment in a multivariable logistic regression model (odds ratio = 0.56 [95% CI = 0.31-099]; P = .046). There also was a 24% reduction in readmission days within the first 30 days after the index admission ( P < .0001), and readmission cost savings were found to be greater than the costs of staffing the H2H clinic. In summary, the H2H program is cost-effective, with significant improvements in survival, readmission days, and readmission costs over 30 days.

Objectives: Pulmonary hypertension portends worse outcomes in cardiac valve surgery; however, isolated pulmonary artery pressures may not reflect patients' global cardiac function accurately. To better account for the interventricular relationship, the authors hypothesized that patients with greater pulmonary-systemic ratios (mean pulmonary arterial pressure)/(mean systemic arterial pressure) would correlate with worse outcomes after valve surgery., Design: Retrospective cohort study., Setting: Single academic hospital., Participants: The study comprised 314 patients undergoing valve surgery with or without coronary artery bypass grafting (2004-2016) with Society of Thoracic Surgeons predicted risk scores and preoperative right heart catheterization., Interventions: None., Measurements and Main Results: The pulmonary-systemic ratio was calculated as follows: mean pulmonary arterial pressure/mean systemic arterial pressure. Patients were stratified by pulmonary-systemic ratio quartile. Logistic regression was used to assess the risk-adjusted association between pulmonary-systemic ratio or mean pulmonary arterial pressure. Median pulmonary-systemic ratio was 0.33 (Q1-Q3: 0.23-0.65); median pulmonary arterial pressure was 29 (21-30) mmHg. Patients with the highest pulmonary-systemic ratio had the highest rates of morbidity and mortality (p < 0.0001). A high pulmonary-systemic ratio was associated with longer duration in the intensive care unit (p < 0.0001) and hospital (p < 0.0001). After risk-adjustment, pulmonary-systemic ratio and pulmonary arterial pressure were independently associated with morbidity and mortality, but the pulmonary-systemic ratio (odds ratio 23.88, p = 0.008, Wald 7.1) was more strongly associated than the pulmonary arterial pressure (odds ratio 1.035, p = 0.011, Wald 6.5)., Conclusions: The pulmonary-systemic ratio is more strongly associated with risk-adjusted morbidity and mortality in valve surgery than pulmonary arterial pressure. By integrating ventricular interactions, this metric may better characterize the risk of valve surgery., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Pulmonary hypertension (PH) is characterized by increased pulmonary vascular resistance leading to right heart failure. Elevated right atrial (RA) pressure reflects right ventricular (RV) pressure overload and is an established risk factor for mortality in PH. We hypothesized that PH patients with an increased ratio of RA to LA volume index (RAVI/LAVI), would have increased mortality., Methods: We evaluated the association of RAVI/LAVI with mortality in 124 patients seen at a single academic center's PH clinic after adjusting for the REVEAL risk score, an established risk score in PH. LA and RA volume indices were measured in the four-and two-chamber views by two independent researchers. Multivariable logistic regression was used to model the independent association of RAVI/LAVI with survival., Results: Among 124 patients (mean age 62 ± 12.7 years, 68.6% female), each unit increase in RAVI/LAVI was associated with a nearly twofold increase in mortality (OR: 1.91, 95% CI: 1.20-3.04). In a multivariable logistic regression, each unit increase in RAVI/LAVI was associated with a nearly twofold increase in mortality (OR: 1.73, 95% CI: 1.003-2.998). Furthermore, RAVI/LAVI in the highest quartile (>1.42) was significantly associated with elevated right atrial pressure (RAP) to pulmonary artery wedge pressure ratio (RAP/PAWP) (0.76 ± 0.41, P = 0.02) compared with the lowest quartile (<0.77), suggesting an interaction between invasive hemodynamic data, atrial structural changes, and mortality in PH., Conclusions: Increased RAVI/LAVI in PH is associated with decreased survival and accounts for atrial structural remodeling related to invasive hemodynamics. These findings support further study of this index in predicting outcomes in PH., (© 2018 Wiley Periodicals, Inc.)

Background: The 6-minute walk test (6MWT) is a simple functional test that can predict exercise capacity and is widely employed to assess treatment outcomes. Although mortality with transcatheter mitral valve repair (TMVr) using the MitraClip (Abbott Vascular, Menlo Park, CA) is significantly less than for open mitral valve surgery in high-risk patients, identifying which patient will benefit the most from TMVr remains a concern. There are limited prognostic metrics guiding patient selection and, no studies have reported relationship between prolonged hospitalization and 6MWT. This study aimed to determine if the 6MWT can predict prolonged hospitalization in patients undergoing TMVr by MitraClip., Methods: We retrospectively reviewed 162 patients undergoing 6MWT before TMVr. Patients were divided into three groups according to the 6MWT distance (6MWTD) using the median (6MWTD ≥219 m, 6MWTD <219 m, and Unable to Walk). Multivariate logistic regression model was applied to select the demographic characteristics that were associated with the prolonged hospitalization defined as total length of stay ≥4 days in the study., Results: We found that 6MWT (odds ratio 3.64, 95% confidence interval 2.03-6.52, P < 0.001) was independently associated with prolonged hospitalization after adjustment in multivariate analysis. Area under the curve of 6MWT for predicting prolonged hospitalization was 0.79 (95% confidence interval 0.72-0.85)., Conclusions: Our study demonstrates that 6MWT was independently associated with prolonged hospitalization in patients with TMVr, and has a good discriminatory performance for predicting prolonged hospitalization., (© 2018 Wiley Periodicals, Inc.)

Background: This study evaluated the utility of a novel index, pulmonary arterial (PA) proportional pulse pressure (PAPP; range 0-1, defined as [PA systolic pressure - PA diastolic pressure] / PA systolic pressure), in predicting mortality in patients with World Health Organization group 1 pulmonary hypertension (PH)., Hypothesis: Low PAPP is associated with increased 5-year mortality independent of a validated contemporary risk-prediction equation (Pulmonary Hypertension Connection [PHC] equation)., Methods: In a group of 262 patients in the National Institutes of Health Primary Pulmonary Hypertension (NIH-PPH) Registry, PAPP and the PHC risk equation were used to predict mortality during 5 years of follow-up using Cox proportional hazards models. Kaplan-Meier survival curves were used to compare mortality among PAPP quartiles, and significance was tested using the log-rank test., Results: Patients in the lowest quartile (PAPP ≤0.47) had a significantly higher 5-year mortality than did patients in higher quartiles (log-rank P = 0.016). In a Cox model adjusted for the PHC equation, PAPP remained significantly associated with 5-year mortality (hazard ratio: 0.74 per 0.10 increase in PAPP, 95% confidence interval: 0.61-0.90). The χ 2 statistic for the single PAPP covariate in this model was 8.8 (P = 0.003), which compared favorably with the χ 2 statistic of 15.2 (P < 0.0001) for the multivariable PHC equation., Conclusions: PAPP, an index of ventricular-arterial coupling, is independently associated with survival in World Health Organization group 1 PH. The use of this easily measurable index for guiding risk stratification needs further investigation., (© 2017 Wiley Periodicals, Inc.)

An ensemble of J HH , J CH , and J CC values was measured in aqueous solutions of methyl α- and β-d-idohexopyranosides containing selective 13 C-enrichment at various carbons. By comparing these J-couplings to those reported previously in the α- and β-d-idohexopyranoses, methyl glycosidation was found to affect ring conformational equilibria, with the percentages of 4 C 1 forms based on 3 J HH analysis as follows: α-d-idopyranose, ∼18%; methyl α-d-idopyranoside, ∼42%; methyl β-d-idopyranoside, ∼74%; β-d-idopyranose, 82%. J CH and J CC values were analyzed with assistance from theoretical values obtained from density functional theory (DFT) calculations. Linearized plots of the percentages of 4 C 1 against limiting J CH and J CC values in the chair forms were used to (a) determine the compatibility of the experimental J CH and J CC values with 4 C 1 / 1 C 4 ratios determined from J HH analysis and (b) determine the sensitivity of specific J CH and J CC values to ring conformation. Ring conformational equilibria for methyl idohexopyranosides differ significantly from those predicted from recent molecular dynamics (MD) simulations, indicating that equilibria determined by MD for ring configurations with energetically flat pseudorotational itineraries may not be quantitative. J-couplings in methyl α-l-[6- 13 C]idopyranosiduronic acid and methyl α-d-[6- 13 C]glucopyranosiduronic acid were measured as a function of solution pH. The ring conformational equilibrium is pH-dependent in the iduronic acid.

Background: This study evaluated the novel index pulmonary arterial proportional pulse pressure (PAPP) in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial., Methods and Results: Multivariable Cox proportional hazards and logistical regression were used to model 6-month death; death, transplantation, or left ventricular assist device (DTLVAD); and DTLVAD or heart failure rehospitalization (DTLVADHF) with respect to PAPP. Among 175 patients with final hemodynamic data, 15.5% and 33.9%, respectively, died in optimal PAPP (PAPP >0.50) and nonoptimal PAPP (PAPP ≤0.50) groups (P = .008), and PAPP was independently associated with death, DTLVAD, and DTLVADHF (P < .01 for all outcomes). The hypothesized logistic regression model with pulmonary capillary wedge pressure, creatinine, and nonoptimal PAPP had an area under the curve of 0.818 (P < .0001) for death. Furthermore, PAPP as a continuous variable was the most powerful predictor of DTLVADHF (hazard ratio 0.793 per 0.1 increase in PAPP [95% confidence interval 0.659-0.955], chi square 8.80; P = .01) in the Cox model, with no other clinical, laboratory, or hemodynamic parameters significant after adjustment for PAPP., Conclusions: PAPP, a novel parameter for right-sided proportional pulse pressure, is an independent and powerful predictor of adverse clinical outcomes in advanced HF. Increased PAPP promises to be a useful therapeutic target in patients with pulmonary arterial pressure assessment., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Diastolic pulmonary gradient (DPG), calculated as the difference between pulmonary artery diastolic pressure and mean pulmonary capillary wedge pressure ≥ 7 mmHg is associated with pulmonary vascular disease and portends poor prognosis in heart failure (HF). The prognostic relevance of DPG in group 1 pulmonary hypertension (PH) is uncertain., Methods: Using the Pulmonary Hypertension Connection (PHC) risk equation for 225 patients in the NIH-PPH, the 5-year probability of death was calculated, which was then compared with DPG using a Cox proportional hazards model. Kaplan-Meier survival curves were determined for two cohorts using the median DPG of 30 mmHg as cutoff, and significance was tested using the log-rank test., Results: The mean age was 38.1 ± 16.0 years old, 63% female, and 72% were "white". The mean DPG was 31.6 mmHg ± 13.8 mm Hg and only 1.8% had a DPG <7 mm Hg. Increasing DPG was significantly associated with increased 5-year mortality even after adjustment for the PHC risk equation (HR 1.29 per 10 mm Hg increase). When DPG was dichotomized based on the median of 30 mm Hg, the HR for DPG >30 mm Hg with respect to 5-year mortality was 2.03. After adjustment for pulmonary artery systolic pressure (PASP), increasing DPG remained significantly associated with decreased 5 years survival (HR 1.99 for DPG > 30 mm Hg)., Conclusions: DPG is independently associated with survival in group 1 PH patients even after adjustment for the PHC risk equation or PASP. Patients with increased DPG had a 2-fold increased risk of mortality. The use of DPG for guiding treatment and prognosis in group 1 PH should be further investigated., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Assessment of diffuse right ventricular (RV) fibrosis is of particular interest in pulmonary hypertension (PH) and heart failure (HF). Current cardiovascular magnetic resonance (CMR) T1 mapping techniques such as Modified Look-Locker inversion recovery (MOLLI) imaging have limited resolution, but accelerated and navigator-gated Look-Locker imaging for cardiac T1 estimation (ANGIE) is a novel CMR sequence with spatial resolution suitable for T1 mapping of the RV. We tested the hypothesis that patients with PH would have significantly more RV fibrosis detected with MRI ANGIE compared with normal volunteers and patients having HF with reduced (LV) ejection fraction (HFrEF) without co-existing PH, independent of RV dilitation and dysfunction., Methods: Patients with World Health Organization group 1 or group 4 PH, patients with HFrEF without PH, and normal volunteers were recruited to undergo contrast-enhanced CMR. RV and LV extracellular volume fractions (RV-ECV and LV-ECV) were determined using pre-contrast and post-contrast T1 mapping using ANGIE (RV and LV) and MOLLI (LV only)., Results: Thirty-two participants (53.1% female, median age 52 years, IQR 26-65 years) were enrolled, including n = 12 with PH, n = 10 having HFrEF without co-existing PH, and n = 10 normal volunteers. ANGIE ECV imaging was of high quality, and ANGIE measurements of LV-ECV were highly correlated with those of MOLLI (r = 0.91; p < 0.001). The RV-ECV in PH patients was 27.2% greater than the RV-ECV in normal volunteers (0.341 v. 0.268; p < 0.0001) and 18.9% greater than the RV-ECV in HFrEF patients without PH (0.341 v. 0.287; p < 0.0001). RV-ECV was greater than LV-ECV in PH (RV-LV difference = 0.04), but RV-ECV was nearly equivalent to LV-ECV in normal volunteers (RV-LV difference = 0.002) (p < 0.0001 for RV-LV difference in PH versus normal volunteers). RV-ECV was linearly associated with both increasing RVEDVI (p = 0.049) and decreasing RVEF (p = 0.04) in a multivariable linear model, but PH was still associated with greater RV-ECV even after adjustment for RVEDVI and RVEF., Conclusions: Pre- and post-contrast ANGIE imaging provides high-resolution ECV determination for the RV. PH is independently associated with increased RV-ECV even after adjustment for RV dilatation and dysfunction, consistent with an independent effect of PH on fibrosis. ANGIE RV imaging merits further clinical evaluation in PH.

Over the past 15 years, the field of mechanical circulatory support has developed significantly. Currently, there are a multitude of options for both short and long term cardiac support. Choosing the appropriate device for each patient depends on the amount of support needed and the goals of care. This article focuses on long term, implantable devices for both bridge to transplantation and destination therapy indications. Implantation strategies, including the appropriate concomitant surgeries are discussed as well as expected long term outcomes. As device technology continues to improve, long term mechanical circulatory support may become a viable alternative to transplantation.

Left ventricular assist devices (LVADs) are increasingly utilized in the management of advanced heart failure. A transcutaneous driveline is necessary to power the LVAD, and although this technology has improved over the years in terms of smaller size and increased durability, driveline complications continue to develop in up to 20% of all devices implanted. Driveline infections are associated with significant morbidity and mortality. As more patients live longer with ventricular assist devices, minimizing driveline infections is paramount. A systematic, multidisciplinary approach can be used to develop a strategy to prevent, recognize and treat driveline infections. In this paper, we describe our approach to driveline management which has resulted in zero driveline infections between January 2012 and March 2014.

Background & Aims: The risk of gastrointestinal (GI) bleeding (GIB) and thromboembolic events may increase with continuous-flow left ventricular assist devices (CF-LVADs). We aimed to characterize GIB and thromboembolic events that occurred in patients with CF-LVADs and compare them with patients receiving anticoagulation therapy., Methods: We performed a retrospective analysis of 159 patients who underwent CF-LVAD placement at 2 large academic medical centers (mean age, 55 ± 13 y). We identified and characterized episodes of GIB and thromboembolic events through chart review; data were collected from a time period of 292 ± 281 days. We compared the rates of GIB and thromboembolic events between patients who underwent CF-LVAD placement and a control group of 159 patients (mean age, 64 ± 15 y) who received a cardiac valve replacement and were discharged with anticoagulation therapy., Results: Bleeding events occurred in 29 patients on CF-LVAD support (18%; 45 events total). Sixteen rebleeding events were identified among 10 patients (range, 1-3 rebleeding episodes/patient). There were 34 thrombotic events among 27 patients (17%). The most common source of bleeding was GI angiodysplastic lesions (n = 20; 44%). GIB and thromboembolic events were more common in patients on CF-LVAD support than controls; these included initial GIB (18% vs 4%, P < .001), rebleeding (6% vs none, P = .001), and thromboembolic events (17% vs 8%, P = .01)., Conclusions: Patients with CF-LVADS receiving anticoagulants have a significantly higher risk of GIB and thromboembolic events than patients receiving anticoagulants after cardiac valve replacement surgery. GI angiodysplastic lesions are the most common source of bleeding., (Copyright © 2014 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Objective: Several strategies have been used to reduce the incidence of right ventricular failure after left ventricular assist device (LVAD) placement, including pulmonary vasodilation. The inhaled prostacyclin, epoprostenol, selectively dilates the pulmonary vasculature of ventilated areas of the lung, but also has been shown to inhibit platelet aggregation.(1) The authors evaluated the impact of early initiation of epoprostenol administration during LVAD placement on pulmonary artery pressures, use of vasoactive drugs, and blood loss., Design: Retrospective data review., Setting: Single center, university hospital., Participants: A total of 37 consecutive patients undergoing LVAD (HeartMate II) placement were included., Interventions: In the first group of 23 patients (group 1), inhaled epoprostenol was not initiated until weaning from cardiopulmonary bypass (CPB). In a subsequent group of 14 patients (group 2), inhaled epoprostenol was started shortly after induction of anesthesia and continued throughout and post-CPB., Measurements: Mean and systolic pulmonary artery pressures (mPAP, sPAP), vasoactive drugs, as well as hemodynamic parameters, blood loss, and use of blood products were recorded at the following time points: Baseline (BL), pre-CPB, post-CPB, and during postoperative days (POD) 0, 1, and 2. Data are presented as mean±SD or median [25%, 75%]., Results: Groups did not differ in demographic characteristics and comorbidities. BL sPAP (41±13 v 46±15 mmHg; p = 0.051) and mPAP (32±8 v 34±8 mmHg; p = 0.483) values were not different between the groups. Systolic and mPAP in group 1 were significantly lower in the postoperative period compared with BL (sPAP on POD 0: 34±6 mmHg; p<0.001; mPAP on POD 0, 1, and 2: 24±4 mmHg, 25±4 mmHg, 27±6 mmHg; p<0.001-0.003)). In contrast, in group 2, sPAP as well as mPAP were significantly lower during weaning from CPB (sPAP: 37±8; p = 0.002; mPAP: 28±5 mmHg; p = 0.016) as well as in the postoperative period (sPAP on POD 0, 1 and 2: 34±7, 35±7, and 37±10 mmHg; p<0.001-0.004; mPAP on POD 0, 1, and 2: 24±4 mmHg, 25±5 mmHg, 27±6 mmHg; p<0.001-0.006). Blood loss on postoperative day 0 was significantly lower in group 1 (1646 mL [1137, 2300] v 2915 mL [2335, 6155]; p = 0.006). Epoprostenol was a significant predictor of blood loss in the regression model (p<0.001) but did not predict a change in sPAP., Conclusions: Inhaled prostacyclin reduces sPAP and mPAP in the postoperative period after LVAD placement regardless of the timing of initiation. Early initiation seems to reduce sPAP as well as mPAP more effectively during the weaning process from CPB. However, early initiation is associated with an increased blood loss in the immediate postoperative period. The concept of preventively "bathing" the lung in prostacyclin should be evaluated critically in a prospective fashion to adequately examine this question., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: This study assessed the impact of pulmonary hypertension (PH) on morbidity and mortality after the most common cardiac operations and evaluated the accuracy of the Society of Thoracic Surgeons (STS) risk model for patients with PH., Methods: At a single center between 1994 and 2010, all adult cardiac operations performed with recorded preoperative mean pulmonary arterial pressure (MPAP) and STS predicted mortality were reviewed. MPAP was defined as normal (<25 mm Hg) or as mild (25-34 mm Hg), moderate (35-44 mm Hg), or severe (≥ 45 mm Hg) PH. Multivariate analysis was performed to elucidate the contribution of PH to morbidity and mortality., Results: In all, 3343 patient records were reviewed. Coronary artery bypass grafting (CABG) was the most common procedure (67.5%), followed by aortic valve replacement (24.9%) and mitral valve procedures (6.3%). Postoperative complications and mortality increased with increasing MPAP. Multivariable analysis found that both moderate (odds ratio, 7.17; P < .001) and severe (odds ratio, 13.73; P < .001) PH were significantly associated with increased mortality, even after accounting for STS risk. A subset analysis of isolated CABG cases revealed markedly increased mortality for all categories of PH (mild odds ratio, 1.99; moderate odds ratio, 11.5; severe odds ratio, 38.9; P < .001)., Conclusions: Morbidity and mortality were independently associated with PH. Observed mortality was significantly higher than predicted by the STS model for patients with moderate and severe PH, particularly in isolated CABG. Addition of PH to the STS risk model should be considered, or alternative tools should be used to assess risk in these patients., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Paravalvular leaks following valve replacement can result in heart failure and hemolysis. Surgical intervention is the treatment of choice, but it carries substantial risk of morbidity and mortality. Percutaneous techniques using devices designed for congenital heart disease are increasingly applied to the treatment of paravalvular leaks. We present the case of a mitral paravalvular leak treated with an Amplatzer occluder device. Unfortunately, the device occluded flow through the mitral valve, resulting in symptomatic mitral stenosis requiring surgical intervention., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

We report the first documented case of HeartMate II® left ventricular assist device (LVAD) reimplantation following Cohn Teflon felt plug repair of the initial left ventricular apical cannulation site. This case highlights the current limitations of the predictability of myocardial recovery while describing an effective technique for possible future LVAD reimplantation., (© 2012 Wiley Periodicals, Inc.)

Late stages of hypertrophic cardiomyopathy (HCM) result in medically refractory heart failure. Current treatments include septal myomectomy or alcohol ablation; however, not all patients are eligible for these procedures. We describe the technical aspects of implantation of a HeartMate II left ventricular assist device as a bridge to transplant therapy for a patient with HCM and end-stage heart failure. Pre- and post-operative imaging demonstrates the importance of establishing a functional inflow tract for the device., (© 2011 Wiley Periodicals, Inc.)

Cardiovascular abnormalities are well-known manifestations of tertiary syphilis infections. Most notable in this regard is syphilitic aortitis, which tends to result in aortic root dilatation and its associated complications. A less common manifestation of syphilitic aortitis is coronary artery ostial narrowing related to aortic wall thickening. Herein, we present the case of a 32-year-old female who died of a myocardial infarct due to coronary artery ostial stenosis secondary to syphilitic aortitis., (Copyright 2006 S. Karger AG, Basel.)