Search

Left ventricular assist devices (LVAD) have evolved, and the latest continuous flow pumps are smaller and more durable, with a lower risk of thrombosis. LVAD outflow graft thrombosis (LVAD-OGT) is rare. Our case describes a patient with stable LVAD function, actively being treated for infective endocarditis (IE), who presented with sudden pump failure and cardiogenic shock. A 44-year-old male with a history of stage D heart failure underwent HeartMate 3 implant in August 2020, chronic MSSA driveline infection, a prior admission for MSSA bacteremia, and MV endocarditis discharged on IV antibiotics. A week later, presented with sudden low-flow alarms without changes to RPMs. The MAP was 50 mmHg, and LVAD parameters showed a flow of 2.3 L/min, speed of 5600 RPM, pulsatility index of 3.5, and power of 3.7 watts. Invasive hemodynamics revealed a CVP of 15 mmHg, PCWP of 30 mmHg, and CI of 1.8 L/min/m2. Labs showed a stable CBC, normal CMP, LDH, and therapeutic INR at 3. Blood cultures were negative. A transthoracic echocardiogram (TTE) showed severe LV dysfunction, dilated left and right ventricles, severe MR, and inconsistent opening of the AV with each cardiac cycle. Due to high suspicion of LVAD-OGT, CTA was performed, which confirmed the same (Figures 1-4). He underwent LVAD exchange. Intraoperative cultures were negative. The LVAD was submitted for investigation, which showed a significant thrombus in the inlet and the remaining pump (Figures 5-8). Our patient demonstrates a rare case of LVAD-OGT that may have been precipitated by IE. Findings consistent with LVAD-OGT include low-flow MAPs in conjunction with low-flow alarms unresponsive to fluid resuscitation and no evidence of blood loss, unchanged RPMs, insufficient LV unloading evidenced by dilated LV and severe MR on TTE as well as elevated CVP and PCWP. LVAD-OGT can occur in serious bacterial infections. LVAD patients are at an increased risk for IE due to the presence of an intracardiac foreign material. We theorize that IE can contribute to pump thrombosis through 1) bacterial colonization of the LVAD, thereby promoting clot formation, and 2) the systemic inflammation secondary to the bacterial infection leading to increased clotting factors and decreased clotting inhibitors. IE and LVAD-OGT are exclusively considered to have high mortality and thus require prompt diagnosis and intervention in LVAD patients. They are listed for a heart transplant or, like our patient, undergo urgent device exchange when they present in cardiogenic shock. Managing these patients is challenging and requires a multidisciplinary approach involving closely monitoring anticoagulation therapy, antibiotic therapy, and LVAD flow. [ABSTRACT FROM AUTHOR]

The coronavirus disease 2019 pandemic disrupted health care delivery in every respect, including critical care resources and the transport of patients requiring extracorporeal membrane oxygenation. Innovative solutions allowing for safe helicopter air transport of these critical patients is needed because extracorporeal membrane oxygenation resources are only available in specialty centers. We present a case demonstrating the interfacility collaboration of care for a patient with coronavirus disease 2019 infection and the lessons learned from the air transport. Careful planning, coordination, communication, and teamwork contributed to the safe transport of this patient and several others subsequently. [ABSTRACT FROM AUTHOR]

The article discusses Survival After Veno-Arterial Extracorporeal membrane oxygenation (ECMO). Topics discussed include association between Veno-Arterial ECMO (SAVE) and Respiratory ECMO Survival Prediction (RESP) scores and survival; survival to discharge rates; and patients initiated on ECMO through a mobile program which have improved short-term survival compared with those initiated in-house.

Background: Enlargement of the left atrium is a marker of mortality in the general population. Left atrial volume index (LAVI) has long been proposed as a measure of prognosis in patients with heart failure (HF). The aim of this meta-analysis was to assess the utility of using baseline LAVI as an independent predictor of all-cause mortality in patients with HF. Methods: A search of Medline and Embase bibliographic databases was performed to identify studies meeting the following inclusion criteria: 1) studies evaluating a cohort of patients with HF (both reduced and preserved ejection fraction); 2) studies conduct-ing multivariate analysis or patient matching to determine the relationship between baseline LAVI measured by echocardiography and all-cause mortality; and 3) studies reporting data on the relationship between baseline LAVI (per difference in mL/m²) and all-cause mortality. Adjusted hazard ratios depicting the association between baseline LAVI and all-cause mortality were pooled using traditional random-effects meta-analysis. Results: 1,188 publications were reviewed from which four studies were included in the present meta-analysis. We found each 10 mL/m² increase in baseline LAVI was associated with a 22% increased adjusted hazard of all-cause mortality (95% confidence interval, 13% to 31%, I² = 14%). Conclusion: Baseline LAVI is an important independent predictor of all-cause mortality in patients with heart failure and should be reported routinely in these patients undergoing echocardiography. [ABSTRACT FROM AUTHOR]

Objective: To determine whether a novel, service-centric, medical emergency team (MET) model can impact cardiac arrest (CA) rates. Methods: A retrospective pre- vs. postintervention analysis was performed on patients ≥18 years who had a CA between 2007 and 2012. A service centric MET model was initially implemented on the inpatient cardiology service and expanded hospital wide during 2008-2009, maturing to 10 teams in 2010. Service centric is defined as a medical or surgical service-specific MET team based on the location of the patient. Results: The rate of CA (per 1,000 hospital days) in the year 2007 prior to the initiation of MET was compared to rates during program maturation (2008/2009) and after full maturation to 10 teams (2010-2012). A total of 1,140,233 hospital-care days were analyzed between 2007 and2012, with 745 CAs recorded (0.65 events per 1,000 hospital days). The overall CA rate was higher prior to MET initiation (0.84 in 2007) compared to postinitiation (0.59 in 2008/09) and maturation to 10 teams (0.64 in 2010-12) (P<0.003 for both pre- vs postcomparisons). No differences in CA rates were detected between either post-MET initiation time frames (P=0.342). Similar trends in CA rates were observed in the intensive care unit (ICU) (3.96 vs 2.14 vs 2.68 per 1,000 hospital daysin2007,2008/2009,and2010-2012respectively, with P<0.001 for both pre- vs postcomparisons). Conclusions: A service-centric MET program was associated with a reduction in the rate of CAs both hospital wide and in the ICU. These observations maybe explained by the earlier intervention in care of unstable patients by an expanded group of caregivers. [ABSTRACT FROM AUTHOR]

Background: While advancements in ventricular assist device (VAD) therapy have improved survival and quality of life for select patients with advanced heart failure (HF), variations in provider knowledge and opinions may ultimately serve as barriers to therapy. Methods and Results: A 12-item survey assessing experience, knowledge, and perspectives of VAD therapy was sent to 106 practicing cardiologists at three neighboring institutions. We received 34 responses for a total response rate of 32.1%. The majority of respondents elected to refer patients with refractory disease for VAD therapy, while only 29.4% elected to refer when standard medical therapy is withdrawn due to hypotension. Conclusions: While providers are well-informed on the fundamentals of advanced therapy, identifying patients with advanced HF who may benefit from referral remains an educational challenge. An automated referral program that identifies patients with advanced HF based on validated clinical parameters could increase appropriately timed referrals to HF specialists to further improve survival and quality of life outcomes with advanced therapy. [ABSTRACT FROM AUTHOR]

The use of Left Ventricular assist devices (LVADs) for mechanical circulatory support has become a standard therapy for some patients with end-stage heart failure. Although presentation and consequences of ventricular arrhythmias (VA) in LVAD supported patients are well described and often stabilized by the mechanical support, presence of asystole is less commonly reported. Our patient is a 75-year-old male with advanced ischemic cardiomyopathy requiring cardiac resynchronization therapy-defibrillator (CRT-D) and ultimately HeartMate II LVAD. Post implantation, his CRT-D was abandoned after it reached the elective replacement indicator as he had no VAs and was not pacer dependent. He now presented with a new onset of low flow alarms that started earlier in the day. He appeared stable, pleasant and in a humorous mood. He reported lightheadedness but denied syncope. While in the ED, the patient was noted to be asystolic. His mean arterial pressure was in the 50s. Physical exam was unremarkable with the expected LVAD hum and lack of pulses. LVAD parameters revealed decreased Flow (2.5 from baseline 5.1) and Pulsatility Index (2.7 from baseline 4.9). Patient subsequently underwent implantation of a new battery with reactivation of his previously abandoned pacemaker leads with resultant hemodynamic improvement. Ultimately, he was discharged home in stable condition. Discussion: Very few cases of asystolic LVAD patients without immediate hemodynamic collapse are described. Similarly to ventricular arrhythmias, the hypothesized physiology for stability is this quasi-Fontan circulation, where low pulmonary vascular resistance with elevated central venous pressure allows pulmonary vasculature perfusion and left atrial filling. In this case, low flow alarms and decreased PI were due to decreased left ventricular preload in the setting of asystole. Ventricular arrhythmias remain common after LVAD implantation, asystole, as in the present case can equally be an issue. This is particularly true as many of LVAD supported patients have CRT-Ds implanted in the setting of pre-existent left bundle branch blocks, which can progress to complete heart block or asystole. Thus, It might not always be the case that LVAD supported patients don't benefit from maintaining ICD function. Conclusion: Traditionally unstable asystole and ventricular arrhythmia can be well tolerated in the LVAD population due to quasi-Fontan physiology. ICD role in LVAD patients is currently unclear, and should be a part of shared decision making with the patient. Yes, there may be such a thing as, "stable" asystole. [ABSTRACT FROM AUTHOR]

A recent trend favoring donor allocation to sicker patients has led to a rise in the number of patients undergoing heart transplantation (HT) on Extracorporeal membrane oxygenation (ECMO) support. Traditionally, these sick patients in cardiogenic shock were managed with biventricular support while awaiting HT. In this context, we examined short-term survival in patients bridged with biventricular devices (BiVAD) or ECMO in the contemporary era of heart transplantation before the change in the donor allocation strategy. We identified adult patients listed for HT who were bridged with an ECMO or BiVAD between 2000 and 2018 in the Scientific Registry of Transplant Recipients. We compared 30-day and 1-year survival with the Kaplan-Meier method. Using inverse propensity treatment weighting, we constructed doubly-robust Cox proportional hazards regression models to determine the risk-adjusted influence of support type on survival. Of the 1495 listings, 868 (58.1%) were bridged with BiVAD and 627 (41.9%) with ECMO. 730 underwent successful HT; 528 (72.3%) and 202 (27.7%) were bridged with BiVAD, or ECMO, respectively. The patients in ECMO group had higher prevalence of pre-transplant ventilator support (30.7% vs 6.3%, p<0.0001), dialysis (15.8% vs 8.0%, p-0.005) inotropes (36.6% vs 22.4%, p<0.0001) along with a higher IMPACT score (11.5 vs 5.5, p<0.0001). Unadjusted 30-day and 1-year estimated survival was greater in BiVAD than in ECMO patients (Figure). After risk-adjustment, BiVAD patients still had a higher 30-day (HR 1.67, 95% CI 0.87-3.22; p=0.1251) and 1-year survival (HR 1.70, 95% CI 1.03-2.80; p=0.0366) than ECMO patients. A minority of patients on BiVAD and ECMO support underwent HT. Besides, the transplantation rate was disproportionately lower in patients on ECMO support. Patients with heart failure bridged to HT with an ECMO experienced worse short-term post-transplant survival. This observation favors a relook into the current heart transplant allocation strategy. [ABSTRACT FROM AUTHOR]

Allosensitization as measured by presence of panel reactive antibodies (PRA) negatively impacts survival in adult heart transplant (HT) recipients. Questions remain whether these trends remain in more contemporary cohorts. We examined the interaction between long-term survival and pre-transplant PRA level in HT recipients from 2000-2018. We identified adult HT recipients between 2000 and 2018 who had a pretransplant PRA in the Scientific Registry of Transplant Recipients. Study cohort was divided into groups with PRA levels; group with 0%, 1-10%, 11-24% and ≥25% PRA levels. We compared 3- and 5-year survival with the Kaplan-Meier method. We constructed Cox proportional hazards regression models to determine the risk adjusted influence of PRA category and PRA as a continuous value on survival. We included 24,655 HT recipients. PRA was 0% in 17,391 (70.5%) recipients, 1-10% in 3,331 (13.5%) recipients, 11-24% in 1,330 (5.4%) recipients, and ≥25% in 2,603 (10.6%) recipients. Patients with a PRA ≥25% were younger, had fewer comorbidities, and were more likely to be on ECMO or LVAD prior to HT. Unadjusted 3- and 5-year estimated survival was lower with increasing PRA category (Figure). After risk-adjustment, 5-year survival was higher for the 0% cohort compared to the 1-10% (HR 1.10, 95% CI 1.02-1.18), 11-24% (HR 1.20, 95%CI 1.08-1.34), and ≥25% (HR 1.16, 95% CI 1.07-1.26). When analyzed continuously, increasing PRA was associated with a lower survival (HR 1.003, 95% CI 1.002-1.005). Sensitivity analysis of those transplanted from 2013-2018 showed similar results. In this contemporary cohort of HT recipients, increasing pretransplant PRA was associated with lower survival. Given the appreciable portion of HT recipients with elevated PRA, improvements in recipient selection and HT management may help improve outcomes. [ABSTRACT FROM AUTHOR]

The patients in cardiogenic shock supported with Extracorporeal Membrane oxygenation (ECMO) or non-dischargeable biventricular mechanical support (BiVAD) are more likely to receive heart transplantation (HT) since the donor allocation system was revamped in 2018, to favor sick patients and reduce waitlist mortality. However, the patients' characteristics and outcomes bridged with BiVAD or ECMO and listed for HT in the contemporary era before the policy changed are not explored. We queried the Scientific Registry of Transplant Recipients database for adults listed for HT with BiVAD or ECMO between 2000 and 2018. Recipient characteristics, including hemodynamic and biochemical variables, are compared between groups. The patients were followed until death, transplant, or end of data availability. Waitlist mortality and successful HT were compared using a Fine and Gray competing risk regression model adjusted for known risk factors. Of the 1495 patients identified, 868 (58.1%) and 627 (41.9%) were bridged with BiVAD or ECMO. Since 2004, a more significant proportion of patients were on BiVAD, but that trend reversed over the past 5 years with more candidates on ECMO (pTrend<0.0001). The patients in ECMO group had higher BMI and were more likely to be on ventilator support with worse renal function. The patients supported on BIVAD were more likely to have prior cardiac surgery and arrhythmias. More overall deaths occurred in the ECMO group (26.0% vs. 14.3%, p<0.0001). A significant proportion of ECMO patients died from cardiovascular causes than BiVAD patients (5.7% vs. 2.5%, p-0.004). The waitlist mortality (sub-hazard ratio [SHR] 1.45, 95% confidence interval [CI] 1.16-1.82), and likelihood of receiving HT (SHR 0.37, 95% CI 0.25-0.53) were significantly worse on ECMO versus BiVAD (Figure). In recent years, there has been a rise in patients bridged to HT with ECMO. However, patients on ECMO suffered higher waitlist mortality and lower transplantation rates. This could, in part, be explained by the sicker profile of patients on ECMO. [ABSTRACT FROM AUTHOR]

Longer wait time and poor outcomes after heart transplant (HT) have been reported among blacks and minor ethnic groups. Whether racial disparity exists in the utilization of mechanical circulatory support, waitlist mortality, and HT rates is unknown. We identified the adult patients listed for HT between 2000 and 2018 in the Scientific Registry of Transplant Recipients. Recipient characteristics, including hemodynamic and biochemical variables, are compared between racial groups-blacks, Asians, and others. The patients were followed until death, transplant, or end of data availability. Waitlist mortality and successful HT were compared between racial groups using a Fine and Gray competing risk regression model adjusted for known risk factors. Of the 57,285 listings; 43,485 (75.9%) were whites; 11,640 (20.3%) were blacks; 1,547 (2.7%) were Asians and 613 (1.1%) were listed as others. Blacks were significantly younger, had higher BMI, non-ischemic cardiomyopathy, hypertension, renal dysfunction, and dialysis (Table). Although more blacks were listed with LVAD bridge vs. whites, ECMO utilization was significantly lower. In the 37,164 patients who received a successful HT, the median wait time to transplant was lower (p<0.0001) for Asians [53 (15, 156) days] compared to White [87 (26, 242) days], Black [86 (28, 245) days] and other races [81.5[23.5, 232] days).Waitlist mortality (as compared to white candidates) for black (HR 0.96, 95% CI 0.85-1.09), Asian (HR 0.78, 95% CI 0.55-1.12) or other race (HR 1.08, 95% CI.72-1.61)) and HT rates were similar across racial groups [black (HR 0.96, 95% CI 0.85-1.09), Asian (HR 0.78, 95% CI 0.55-1.12), other race (HR 1.08, 95% CI.72-1.61)]. While waitlist mortality did not vary by race in patients listed with ECMO or IABP, Asians were more likely to receive HT (HR 1.38, 95% CI 1.10-1.73) (Figure). Overall, waitlist mortality and successful transplantation rates were similar across racial groups. Black HT candidates were less likely to be bridged with ECMO compared with Whites. Asians had higher transplantation rates while supported on ECMO or IABP. [ABSTRACT FROM AUTHOR]

Women continue to be under-represented as heart transplant (HT) recipients. Past studies on survival rates following HT and gender have suggested conflicting data. We compare long-term survival between male and female HT recipients in the contemporary heart transplantation era from 2000-2018 using novel methods. We identified adult HT recipients between 2000 and 2018 in the Scientific Registry of Transplant Recipients. Men and women were matched using overlap propensity score weighting. We compared 10-year survival with the Kaplan-Meier method. We constructed doubly-robust Cox proportional hazards regression models to determine the risk-adjusted influence of gender on survival. Models were adjusted for recipient and donor characteristic including IMPACT score and donor-recipient predicted heart mass (PHM) ratio. The proportionality assumption was tested by inspection of Shoenfeld residuals with covariates being converted to time-varying if significant. We included 36,606 HT recipients. When compared with men, women tended to be younger, have fewer comorbidities, higher PRA, larger IMPACT score and donor-recipient PHM ratio. Unadjusted 10-year estimated survival was similar between men and women (Figure). After risk-adjustment, women had a similar risk of 10-year survival than men (HR 0.94, 95% CI 0.82-1.02; p=0.0974). When comparing between men and women at 1 (p<0.0001) or 5 years (p<0.0001), women had a lower survival versus men but the curves converge around year 6. In this contemporary cohort of HT recipients, women had similar long-term survival to men despite an overall lower risk profile and greater likelihood to receive a size mismatched heart. [ABSTRACT FROM AUTHOR]

Severe obesity (Body Mass Index (BMI) ≥40 kg/m2) is associated with a higher risk of developing severe symptoms and complications of coronavirus disease 19 (COVID-19), independent of other illnesses. Despite this, patients with severe obesity are less likely to receive Veno-Venous Extra Corporeal Membrane Oxygenation (VV-ECMO) support for severe Acute Respiratory Distress Syndrome (ARDS). Given this paradox, we examined the impact of severe obesity on outcomes of adult patients who underwent VV-ECMO implantation for ARDS at our center. We reviewed our ECMO database from May 2013 through May 2020. Adults, who had received VV-ECMO, either in-house or through our mobile ECMO program, were included. We grouped patients into those with BMI ≥40 kg/m2 or not and compared survival at 48 hours, survival to hospital discharge, and hospital length of stay. We conducted multiple logistic and linear regression analyses to analyze the association with categorical and continuous variables, respectively, controlling for patient age, gender, and use of mobile ECMO. We identified 112 consecutive adult VV-ECMO patients; median age was 48 (34, 59) years, 61 (54.5%) were male, 56 (50%) were started on ECMO in-house, the median BMI was 31.7 (27.6, 38.8) Kg/ m2; and 23 (20.5%) had a BMI ≥40 kg/m2. Survival at 48 hours and hospital discharge were 69.6% and 61.6%, respectively; and, median hospital length of stay was 20 (9, 33) days. Logistic regression showed no evidence of an association between severe obesity and either 48-hour (OR 1.04, 95% CI 0.37-2.96) or hospital discharge survival (OR 1.06, 95% CI 0.38-2.93). There was, however, a significant correlation between increasing BMI and longer total hospital length of stay (R2 = 0.34; p = 0.0002) which remained significant in linear regression (p = 0.0002) (Figure). We found no association between severe obesity and survival at 48-hour and hospital discharge in patients supported on VV-ECMO. Severe obesity was associated with a longer hospital stay, however. Our experience suggests that severe obesity alone should not exclude candidacy for VV-ECMO support. [ABSTRACT FROM AUTHOR]