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Background Despite cardiac resynchronization therapy (CRT), some patients with heart failure progress and undergo left ventricular assist device (LVAD) implantation. Management of CRT after LVAD implantation has not been well studied. The purpose of this study was to determine whether RV pacing or biventricular pacing measurably affects acute hemodynamics in patients with an LVAD and a CRT device. Methods and Results Seven patients with CRT and LVAD underwent right heart catheterization. Pressures and oximetry were measured and LVAD parameters were recorded during 3 different conditions: RV pacing alone, biventricular pacing, and intrinsic atrioventricular conduction. Paired t tests were used to evaluate changes within subjects. There were no significant changes in right atrial pressure, pulmonary arterial pressures, pulmonary capillary wedge pressure, cardiac index, or any LVAD parameter (P > .05). Conclusions Our data suggest that CRT probably has no acute hemodynamic effect in patients with LVADs, but further study is needed.

Gastrointestinal bleeding (GIB) remains a major morbid event during continuous flow left ventricular assist device (LVAD) support. This study investigated whether a common hemodynamic profile is associated with GIB in patients with LVADs.A single institution analysis reviewed all patients who underwent right heart catheterization (RHC) following LVAD implant between January 1, 2006, and December 31, 2013, with follow-up through June 2015. Kaplan-Meier and multiphase hazard statistical methods were employed. Among 108 patients with 341 RHC, 55 hospitalizations for GIB occurred within 1 year of RHC. Freedom from GIB at 6 months was 92% in patients with pulse pressure ≥35 mmHg, compared with 76% with pulse pressure 35 mmHg. By multivariable analysis, the significant predictors of GIB were: older age at implant, number of prior GIB, lower pulse pressure, lower mean arterial pressure, and higher right atrial pressure (all P .05). The magnitude of effect is influenced by pulse pressure.Greater pulsatility and less venous congestion, along with other factors, are associated with a lower risk for GIB. It is reasonable to adjust therapeutic strategies to target this hemodynamic profile in patients with a propensity for GIB.

Objectives Patients with cardiogenic shock (CS) supported by Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) have a high mortality. The role of biomarkers in prediction of survival of these patients has not been clearly examined. Soluble Suppression of Tumorigenicity 2 (sST2) and Galactin-3 (Gal-3) are two well-acknowledged prognostic biomarkers in heart failure. Our objective was to analyze the levels of sST2 and Gal-3 in patients with cardiogenic shock supported by VA-ECMO. Methods Sixty five patients with CS supported by VA-ECMO were included in this study. Blood samples were collected prior to VA-ECMO support (t0) and 2 (t2) and 8 (t8) days after. sST2 and gal-3 where assayed by sandwich ELISA technique. Patients were grouped in those who recovered from CS (recovered group) and those received LVAD, heart transplant or died (not recovered group). Results In the recovered group the sST2 levels were statistically different at various time points, whereas in the not recovered group sST2 levels did not change over time. The absolute sST2 concentration was different between groups at t2 of VA-ECMO support. The gal-3 levels changed over time in both the recovered and not-recovered groups and was significantly different at t0-t2. Conclusion In patients with cardiogenic shock supported by VA-ECMO sST2 trend was significantly different between patients who recovered and those who did not. Also, sST2 levels at t2 were higher in the recovered group. Further studies are needed to assess the role of those two prognostic biomarkers in this population.

Introduction Intravenous loop diuretics remain the mainstay of therapy for acute decompensated heart failure (ADHF); however, most physicians rely on clinical experience when choosing a diuretic strategy. Studies have compared continuous versus intermittent loop diuretic strategies, but few have looked at severely ill patients with acute kidney injury (AKI) or on inotropes. Our study aimed to determine the characteristics and outcomes of patients with ADHF receiving continuous versus intermittent loop diuretic strategies without excluding patients with renal failure or later requiring inotropes. Methods Using a retrospective cohort design, we included patients admitted to the University of Alabama at Birmingham Hospital for ADHF who received right heart catheterization from 2012 to 2017. Exclusion criteria included LVEF ≥ 40% and requiring inotropes prior to the index hospitalization. Measures of interest included 30- and 90-day readmissions, need for renal replacement therapy, length of stay, and in-hospital mortality. Continuous and categorical variables were analyzed using student's t-test and chi-square testing. A p-value ≤0.05 was considered significant. Results A total of 206 patients met inclusion criteria. Age, ethnicity, LVEF, type of cardiomyopathy, presence of severe valve disease and comorbidities were similar between patients receiving an intermittent versus continuous loop diuretic strategy. Patients who received a continuous loop diuretic strategy were more likely to be male (71.8% vs 54.5%, p = 0.01), have a higher BMI (32.9 vs 29.3, p = 0.004), have an AKI on admission (52.5% vs 35.1%, p = 0.02), and be on inotropes both pre- and post-RHC (77.6% vs 38.8%, p = Conclusion At our institution, patients receiving a continuous loop diuretic strategy were more likely to be male, have a higher BMI, have an AKI present on admission, and be placed on inotropes during their hospital stay. Patients with this strategy had a longer length of stay but no difference in 30- or 90-day readmissions. Because patients who received continuous loop diuretics were more likely to have acute renal failure and be on inotropes, it will be important to further assess this group's response to continuous versus intermittent loop diuretics as these patients were excluded from prior landmark trials.