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Supplemental Digital Content is available in the text.Targeted blood pressure (BP) control is a goal of left ventricular assist device medical management, but the interpretation of values obtained from noninvasive instruments is challenging. In the MOMENTUM 3 Continued Access Protocol, paired BP values in HeartMate 3 (HM3) patients were compared from arterial (A)-line and Doppler opening pressure (DOP) (319 readings in 261 patients) and A-line and automated cuff (281 readings in 247 patients). Pearson (R) correlations between A-line mean arterial (MAP) and systolic blood pressures (SBP) were compared with DOP and cuff measures according to the presence (>1 pulse in 5 seconds) or absence of a palpable radial pulse. There were only moderate correlations between A-line and noninvasive measurements of SBP (DOP R = 0.58; cuff R = 0.47) and MAP (DOP R = 0.48; cuff R = 0.37). DOP accuracy for MAP estimation, defined as the % of readings within ± 10 mmHg of A-line MAP, decreased from 80% to 33% for DOP ≤ 90 vs.>90 mmHg, and precision also diminished (mean absolute difference [MAD] increased from 6.3 ± 5.6 to 16.1 ± 11.4 mmHg). Across pulse pressures, cuff MAPs were within ±10 mmHg of A-line 62.9%–68.8% of measures and MADs were negligible. The presence of a palpable pulse reduced the accuracy and precision of the DOP-MAP estimation but did not impact cuff-MAP accuracy or precision. In summary, DOP may overestimate MAP in some patients on HM3 support. Simultaneous use of DOP and automated cuff and radial pulse may be needed to guide antihypertensive medication titration in outpatients on HM3 support.

We analyzed humoral immune responses to nonhuman leukocyte antigen (HLA) after cardiac transplantation to identify antibodies associated with allograft rejection. Protein microarray identified 366 non‐HLA antibodies (>1.5 fold, P< .5) from a discovery cohort of HLA antibody–negative, endothelial cell crossmatch–positive sera obtained from 12 cardiac allograft recipients at the time of biopsy‐proven rejection. From these, 19 plasma membrane proteins and 10 autoantigens identified from gene ontology analysis were combined with 48 proteins identified through literature search to generate a multiplex bead array. Longitudinal sera from a multicenter cohort of adult cardiac allograft recipients (samples: n = 477 no rejection; n = 69 rejection) identified 18 non‐HLA antibodies associated with rejection (P< .1) including 4 newly identified non‐HLA antigenic targets (DEXI, EMCN, LPHN1, and SSB). CART analysis showed 5/18 non‐HLA antibodies distinguished rejection vs nonrejection. Antibodies to 4/18 non‐HLA antigens synergize with HLA donor‐specific antibodies and significantly increase the odds of rejection (P< .1). The non‐HLA panel was validated using an independent adult cardiac transplant cohort (n = 21 no rejection; n = 42 rejection, >1R) with an area under the curve of 0.87 (P< .05) with 92.86% sensitivity and 66.67% specificity. We conclude that multiplex bead array assessment of non‐HLA antibodies identifies cardiac transplant recipients at risk of rejection. Using high throughput proteomics and bioinformatics, the authors report the discovery and validation of a novel panel of nonhuman leukocyte antigens that can identify antibodies associated with cardiac allograft rejection. An editorial from Jackson and Glass is on page 2639.

Standardized donor-derived cell-free DNA (dd-cfDNA) testing has been introduced into clinical use to monitor kidney transplant recipients for rejection. This report describes the performance of this dd-cfDNA assay to detect allograft rejection in samples from heart transplant (HT) recipients undergoing surveillance monitoring across the United States. Venous blood was longitudinally sampled from 740 HT recipients from 26 centers and in a single-center cohort of 33 patients at high risk for antibody-mediated rejection (AMR). Plasma dd-cfDNA was quantified by using targeted amplification and sequencing of a single nucleotide polymorphism panel. The dd-cfDNA levels were correlated to paired events of biopsy-based diagnosis of rejection. The median dd-cfDNA was 0.07% in reference HT recipients (2164 samples) and 0.17% in samples classified as acute rejection (35 samples; P= .005). At a 0.2% threshold, dd-cfDNA had a 44% sensitivity to detect rejection and a 97% negative predictive value. In the cohort at risk for AMR (11 samples), dd-cfDNA levels were elevated 3-fold in AMR compared with patients without AMR (99 samples, P= .004). The standardized dd-cfDNA test identified acute rejection in samples from a broad population of HT recipients. The reported test performance characteristics will guide the next stage of clinical utility studies of the dd-cfDNA assay.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jtcvs.2005.08.022 Byline: Nahush A. Mokadam (a), Gregory A. Ewald (b), Ralph J. Damiano (a), Nader Moazami (a) Author Affiliation: (a) Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Mo. (b) Division of Cardiology, Washington University School of Medicine, St Louis, Mo. Article History: Received 13 May 2005; Accepted 17 August 2005 Article Note: (footnote) United Network for Organ Sharing/Organ Procurement and Transplantation Network data retrieval was supported in part by Health Resources and Services Administration contract 231-00-0115. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jtcvs.2005.02.014 Byline: Cliff K. Choong (a), Michael K. Pasque (a), Kim Shelton (b), Beth Kehoe-Huck (b), Gregory A. Ewald (b), Douglas Horstmanshof (b), Nader Moazami (a) Author Affiliation: (a) Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Mo. (b) Division of Cardiology, Washington University School of Medicine, St Louis, Mo. Article History: Received 2 December 2004; Revised 28 December 2004; Accepted 10 February 2005

Acute myocardial infarction (AMI) is an underrecognized phenomenon in patients with continuous-flow left ventricular assist devices (CF-LVAD). Previously, there has been an optimistic expectation of a benign clinical course; however, AMI in LVAD-supported patients can result in profound consequences and management remains controversial. We describe a case series of AMI in four CF-LVAD patients, each with a different presentation, clinical course, treatment, and outcome. The clinical variability and mixed outcomes of these patients highlights the unique challenges in diagnosis and management of AMI in this population, particularly the uncertain role of percutaneous intervention (PCI), and underscores the potentially poor prognosis of this entity. Several key points emerge from this review. First, LVAD-supported patients frequently have underlying abnormalities on the electrocardiogram (ECG) that obscure the diagnosis of AMI. Second, clinicians should have a high degree of suspicion for AMI in the presence of suggestive clinical features, elevated cardiac biomarkers, or new-onset ventricular arrhythmias. Third, the decision to proceed with PCI requires careful evaluation of the risk of hemorrhage, and strong consideration should be given to the use of bleeding avoidance strategies during and after PCI.

This study explored the association of vascular hormones with myocardial recovery and clinical outcomes in peripartum cardiomyopathy (PPCM).

The purpose of this study was to determine the risk factors for ischemic in hemorrhage cerebrovascular events in patients supported by the HeartWare ventricular assist device (HVAD).

This study evaluated the Heartmate Risk Score (HMRS) and its potential benefits in clinical practice.

Arrhythmia is the major cause of death in patients with heart failure, for which -adrenergic receptor blockers are a mainstay therapy. But the role of -adrenergic signaling in electrophysiology and arrhythmias has never been studied in human ventricles.

This study evaluated clinical outcomes associated with erythropoiesis stimulating agent (ESA) use in left ventricular assist devices (LVAD)–supported patients.

Gene expression profiling test scores have primarily been used to identify heart transplant recipients who have a low probability of rejection at the time of surveillance testing. We hypothesized that the variability of gene expression profiling test scores within a patient may predict risk of future events of allograft dysfunction or death.

Despite improvements in the care of patients who have received cardiac transplants, coronary allograft vasculopathy (CAV) remains the most prevalent cause of late allograft failure and cardiac mortality. Few proven therapies are available for this important disease. The presence of coronary collaterals imparts a favorable prognosis in patients with native ischemic heart disease; however, the impact of collaterals in CAV is unknown.

The HeartMate II (HMII) destination therapy (DT) trial demonstrated significant improvements in outcomes in continuous-flow left ventricular assist devices compared with patients implanted with the pulsatile-flow HeartMate XVE. The primary hypothesis of the current study is that trial patients enrolled after the initial data cohort would have better clinical outcomes.

We determined the role of donor-specific antibodies (DSA) and antibodies (Abs) to self-antigens, collagen-V (Col-V), and K-1-Tubulin (KAT) in pathogenesis of acute antibody-mediated rejection (AMR) and cardiac allograft vasculopathy (CAV) after human heart transplantation (HTx).

The cardiac phenotype of hereditary transthyretin amyloidosis (hTTR) usually presents as a restrictive or hypertrophic cardiomyopathy, and, although rarely observed as dilated cardiomyopathy (DCM), TTRis routinely included in DCM genetic testing panels. However, the prevalence and phenotypes of TTRvariants in patients with DCM have not been reported.

Milrinone is a phosphodiesterase type III inhibitor with positive inotropic and vasodilatory effects. A common side effect of milrinone is hypotension from the peripheral vasodilation. Although mild elevations in serum creatinine have been described previously in the setting of milrinone-induced hypotension, acute oligoanuric renal failure requiring renal replacement therapy has not yet been described. This case report is the first to document such a result and to report the successful use of peritoneal dialysis in this setting. Previous case reports documented vasopressin as an effective alternative to catecholamines in the treatment of milrinone-induced hypotension. This report documents the use of four vasopressor agents (including vasopressin) in this patient, with only vasopressin resulting in improvement in systemic vascular resistance and blood pressure. Vasopressin may be the most effective vasopressor agent in the treatment of milrinone-induced hypotension. © 2002 by the National Kidney Foundation, Inc.

Introduction:Peripartum cardiomyopathy (PPCM) is a severe complication of pregnancy which is hallmarked by non-ischemic reduction in left ventricular ejection fraction (LVEF) to <45% late in gestation or shortly postpartum. This study evaluated outcomes among women who required mechanical circulatory support (MCS) for end-stage heart failure in the setting of PPCM.Methods:Thirty female patients 18-46 years of age underwent cardiac surgery for PPCM between 2012-2020. Primary heart transplant patients (n=2) were excluded. PPCM patients with a new MCS requirement (n=28) were classified by device type and escalations in device support.Results:Mean age was 29±7 years and 21 patients (75%) were African American. Median time from delivery to MCS requirement was 418 [91-1201] days. Nineteen (68%) patients required temporary MCS (tMCS): 12 (63%) on intraaortic balloon pump, 9 (47%) on veno-arterial extracorporeal membrane oxygenation, and 4 (21%) on Impella. Nine (32%) patients underwent left ventricular assist device (LVAD) implant after failure of medical therapy. LVEF and left ventricular end-diastolic diameter (LVEDD) at MCS insertion were 14±5mm and 68±11mm, respectively. LVEF progressed to 24%±16% post-insertion and 29%±17% one year (Figure 1). Of the 19 tMCS patients, 5 (26%) required escalations with additional modalities. Ten (53%) patients were bridged to durable LVAD. Complications included right ventricular failure (n=4), stroke (n=2), sepsis (n=1), dialysis (n=5), and cardiac arrest (n=3). Duration of support was 9±7 days for tMCS and 996±625 days for LVAD. Overall survival to discharge was 89% (n=25). Twelve patients underwent transplant (43%) and two (7%) recovered native heart function.Conclusions:Severe PPCM can be effectively managed with tMCS as a bridging strategy to either transplant or durable LVAD. Patients will often require multiple escalations in resource-intensive therapy, but outcomes are excellent with vigilant management.

The shortage of suitable donor hearts has made the selection of potential transplant recipients a critical step in the cardiac transplantation process. Appropriate patients for transplantation should have a high predicted short- and intermediate-term mortality rate despite aggressive medical therapy. Stratifying patients based on the etiology of the heart failure, left ventricular ejection fraction, functional capacity, hemodynamic measurements, the presence of arrhythmias, and neurohormonal activation is useful in defining a high-risk population. The transplant evaluation should focus on risk definition as well as on factors that increase posttransplant morbidity and mortality.

We describe the use of an Impella 5.0 for mechanical support in acute cardiogenic shock after an acute myocardial infarction. A 61-year-old man with a history of severe coronary artery disease who underwent coronary artery bypass grafting with ischemic cardiomyopathy presented with cardiogenic shock after an ST-elevation myocardial infarction. An Impella Recover LP 5.0 (Abiomed, Danvers, MA USA) was inserted via a right axillary side graft, using transesophageal echocardiographic and fluoroscopic guidance. The patient remained in the intensive care unit, where he required a tracheostomy to beweaned off the ventilator. He required renal replacement therapy with subsequent complete recovery. His Impella support was weaned, and on postoperative day 35, the device was removed. The patient developed axillary thrombosis the morning after removal, requiring thrombectomy. Discharge echocardiogram showed mild left ventricular enlargement with global hypokinesis and left ventricular ejection fraction of 25%. The Impella 5.0 device can safely and effectively be used in the long-term support of cardiogenic shock.

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