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Statin-intolerance (SI) has prevalence between 8.0 % and 10 %, and muscular complaints are the most common reason for discontinuation. Bempedoic acid (BA), an ATP citrate lyase inhibitor, decreases hepatic generation of cholesterol, upregulates low-density lipoprotein (LDL) receptor expression in the liver, and eventually clears circulating LDL-cholesterol from the blood. Multiple randomized clinical trials studying BA demonstrate a reduction in LDL levels by 17–28 % in SI. The CLEAR OUTCOME trial established significant cardiovascular benefits with BA. A dose of 180 mg/day of BA showed promising results. BA alone or in combination with ezetimibe is US Food and Drug Administration-approved for use in adults with heterozygous familial hypercholesterolemia and/or established atherosclerotic cardiovascular disease. BA reduced HbA1c by 0.12 % (p < 0.0001) in patients with diabetes. Adverse events of BA include myalgia (4.7 %), anemia (3.4 %), and increased aminotransferases (0.3 %). BA can cause up to four times higher risk of gout in those with a previous gout diagnosis or high serum uric acid levels. Reports of increased blood urea nitrogen and serum creatinine were noted. Current evidence does not demonstrate a reduction in deaths from cardiovascular causes. More studies that include a diverse population and patients with both high and low LDL levels should be conducted. We recommend that providers consider BA as an adjunct to statin therapy in patients with a maximally tolerated dosage to specifically target LDL levels. [Display omitted] • Bempedoic acid (BA), an ATP citrate lyase inhibitor, decreases circulating LDL-C levels. • Randomized clinical trials showed reduction in LDL levels by 17–28 % in statin-intolerant patients with BA. • BA can be used as an adjunct to statin therapy in patients to target LDL levels. [ABSTRACT FROM AUTHOR]

Ebstein's anomaly (EA), a congenital cardiac anomaly, is characterized by apical displacement of the tricuspid valve leaflet(s) into the right ventricle. We present the case of a 61-year-old female with a history of EA, Wolff-Parkinson-White syndrome, and patent foramen ovale (PFO), who presented with worsening hypoxia and confusion, in the setting of left lower extremity cellulitis and abscess. The computed tomography (CT) scan of the head showed a cerebellar infarct with hemorrhagic conversion. Magnetic resonance imaging of the head showed a satellite lesion raising concern for the embolic nature of infarcts. After ruling out cardioembolic causes of cerebellar infarction, her presenting symptoms were attributed to paradoxical septic emboli from the left leg abscess (demonstrated on CT scan of the leg). She was deemed a poor candidate for surgical closure of PFO due to contraindication to use heparin (due to the presence of hemorrhagic stroke) and underlying comorbidities. Septic embolization is a rare but dreaded complication in EA patients with PFO. • Paradoxical emboli can occur in patients with Ebstein's anomaly (EA) and patent foramen ovale (PFO). • The mainstay of management in case of paradoxical embolism lies with the identification and treatment of the underlying cause, such as infective endocarditis, deep vein thrombosis, or infectious source, as in the present case. • The surgical correction of PFO in EA patients should be considered when the patient becomes symptomatic with cyanosis, hypoxia, or manifestations of paradoxical emboli. [ABSTRACT FROM AUTHOR]

• Inotrope formulations avoiding the burdens of continuous IV infusion are needed. • We tested a novel, concentrated formulation of milrinone for inhalation. • Nebulized milrinone was well tolerated and without adverse events. • Intermittent inhalation of milrinone produced therapeutic serum concentrations. • Nebulized milrinone improved invasive hemodynamic parameters. Nonintravenous inotropic-delivery options are needed for patients with inotropic-dependent heart failure (HF) to reduce the costs, infections and thrombotic risks associated with chronic central venous catheters and home infusion services. We developed a novel, concentrated formulation of nebulized milrinone for inhalation and evaluated the feasibility, safety and pharmacokinetic profile in a prospective, single-arm, phase I clinical trial. We enrolled 10 patients with stage D HF requiring inotropic therapy during a hospital admission for acute HF. Milrinone 60 mg/4 mL was inhaled via nebulization 3 times daily for 48 hours. The coprimary outcomes were adverse events and pharmacokinetic profiles of inhaled milrinone. Acute changes in hemodynamic parameters were secondary outcomes. A concentrated nebulized milrinone formulation was well tolerated, without hypotensive events, arrhythmias or inhalation-related adverse events requiring discontinuation. Nebulized milrinone produced serum concentrations in the goal therapeutic range with a median plasma milrinone trough concentration of 39 (17–66) ng/mL and a median peak concentration of 207 (134–293) ng/mL. There were no serious adverse events. From baseline to 24 hours, mean pulmonary artery saturation increased (60% ± 7%–65 ± 5%; P = 0.001), and mean cardiac index increased (2.0 ± 0.5 mL/min/1.73m2–2.5 ± 0.1 mL/min/1.73m2; P = 0.001) with nebulized milrinone. In a proof-of-concept study, a concentrated, nebulized milrinone formulation for inhalation was safe and produced therapeutic serum milrinone concentrations. Nebulized milrinone was associated with improved hemodynamic parameters of cardiac output in a population with advanced HF. These promising results require further investigation in a longer-term trial in patients with inotrope-dependent advanced HF. [ABSTRACT FROM AUTHOR]

A 61-year-old man with end-stage ischemic cardiomyopathy post HeartMate 3 (Abbott laboratories, Chicago, Illinois, USA) left ventricular assist device (LVAD) implant was hospitalized after he had recurrent ventricular tachycardia requiring implantable cardioverter-defibrillator shocks. His transthoracic echocardiogram and computed tomography angiography of the chest showed presence of trace aortic insufficiency (AI) and aortic root thrombus (ART) of non-coronary cusp without obstruction of right or left coronary artery ostium despite therapeutic international normalized ratio. He presented again 3 months later with worsening heart failure signs and symptoms. Transesophageal echocardiogram showed progression to severe AI and persistent ART. Despite hemodynamically guided LVAD speed optimization, inotropic support, and diuresis, the patient continued to deteriorate with worsening renal function. The patient was not a transplant candidate due to frailty. After multi-disciplinary discussion he underwent successful 29-Sapien S3 (Edwards Lifesciences, Irvine, CA, USA) transcatheter aortic valve replacement utilizing distal protection filters in bilateral internal carotid arteries for stroke prevention. This case provides novel insight to physicians treating LVAD patients regarding management of severe AI in the setting of ART. We report a rare approach employed for management of aortic insufficiency (AI) in a patient who also had an aortic root thrombus and left ventricular assist device (LVAD) that traditionally requires cardiac transplantation. Our patient had a favorable outcome with a minimally invasive transcatheter aortic valve replacement. With this case, we hope to generate awareness amongst physicians treating patients about management alternatives and approach of a commonly encountered, life-threatening complication of AI in patients with LVAD. [ABSTRACT FROM AUTHOR]

Cytomegalovirus (CMV) may manifest in various ways. While immunocompetent hosts may be asymptomatic or present with a mononucleosis-like illness, immunocompromised patients can have organ-specific disease capable of significant morbidity and mortality. CMV appendicitis is a particularly rare presentation. A 22-year-old female with a history of orthotopic heart transplantation presented to our hospital with a three-day history of worsening abdominal pain. A computed tomography scan of her abdomen was consistent with acute uncomplicated appendicitis, and she underwent laparoscopic appendectomy. Pathology revealed acute appendicitis with numerous large cells with intranuclear "owl's eye" inclusions characteristic of CMV. Her CMV viral load was elevated at 327,018 IU/ml. She was started on ganciclovir which resulted in improvement of her CMV level to 30,118 IU/ml within three weeks. CMV is a frequent cause of opportunistic infection in solid organ transplant patients and commonly involves the gastrointestinal tract. Acute appendicitis is a rarely reported complication to consider in the differential diagnosis of abdominal pain in immunocompromised patients. Heart transplant recipients are at increased risk for opportunistic infections. Cytomegalovirus (CMV) is a frequent culprit and can present with a broad range of disease. A particularly rare presentation is that of acute appendicitis. We describe a case of a young woman with CMV appendicitis following orthotopic heart transplant. [ABSTRACT FROM AUTHOR]

• Long-term therapy with palliative inotropes is often the only option for patients with advanced heart failure who are not candidates for cardiac transplant or a left ventricular assist device. Comparison of outcome data between dobutamine and milrinone in these patients is limited. • Our study finds improved survival with chronic intravenous milrinone therapy as compared with dobutamine in these patients (1-year mortality 58% vs 84%, P <.001). Improved survival from milrinone is attributed to better optimization of guideline-directed medical therapy, primarily beta-blocker therapy, which is usually not prescribed concomitantly with dobutamine. • There are important prognostic implications of the choice of inotropic agent as long-term therapy for these patients. Even for palliative purposes, milrinone should be the preferred agent owing to better patient survival when combined with optimal guideline-directed medical therapy. We sought to describe and compare outcomes among advanced patients with heart failure (not candidates for orthotopic heart transplant/left ventricular assist device) on long-term milrinone or dobutamine, which are not well-studied in the contemporary era. We included adults with refractory stage D heart failure who were not candidates for orthotopic heart transplant or left ventricular assist device and discharged on palliative dobutamine or milrinone. The primary outcome was 1-year survival. A 6-month predictor of survival analysis was conducted. A total of 248 patients (133 on milrinone, 115 on dobutamine) were included. There were no differences in baseline comorbidities between milrinone and dobutamine cohorts, except for the prevalence of chronic kidney disease, which was higher in the dobutamine group. On discharge, the proportion of patients on beta-blockers and mineralocorticoid antagonists was higher in milrinone group. Overall, the 1-year mortality rate was 70%. The dobutamine cohort had a significantly higher 1-year mortality rate (84% vs 58%, P <0.001). The type of inotrope did not predict survival at 6 months when adjusted for discharge medications and comorbidities. Beta-blockers and angiotensin-converting enzyme/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor continued at discharge predicted survival at 6 months. The 1-year mortality from palliative inotropes remains high. Compared with dobutamine, use of milrinone was associated with improved survival owing to better optimization of guideline-directed medical therapy, primarily beta-blocker therapy. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: There is paucity of data regarding durable left ventricular assist device (LVAD) outcomes in patients with chronic kidney disease (CKD) stages 3-5 and CKD stage 5 on dialysis (end-stage renal disease [ESRD]).Methods and Results: We conducted a retrospective study of Medicare beneficiaries with ESRD and a 5% sample of patients with CKD with an LVAD (2006-2018) to determine 1-year outcomes using the United States Renal Data System database. The LVAD implantation, comorbidities, and outcomes were identified using appropriate International Classification of Diseases, 9th and 10th edition codes. We identified 496 patients with CKD and 95 patients with ESRD who underwent LVAD implantation. The patients with ESRD were younger (59 years vs 66 years; P < .001), had more Blacks (40% vs 24.6%, P = .009), compared with the CKD group. The 1-year mortality (49.5% vs 30.9%, P < .001) and index mortality (27.4% vs 16.7%, P = .014) rates were higher for patients with ESRD. A subgroup analysis showed significantly higher mortality in ESRD vs CKD 3 (49.5% vs 30.2%, adjusted P = .009), but no significant difference in mortality between stage 3 vs 4/5 (30.2% vs 30.8%, adjusted P = .941). There was no significant difference in secondary outcomes (bleeding, stroke, and sepsis/infection) during follow-up between the 2 groups.Conclusions: Patients with ESRD undergoing LVAD implantation had significantly higher index and 1-year mortality rates compared with patients with CKD. [ABSTRACT FROM AUTHOR]

Background: The prognostic value of cardiopulmonary exercise testing (CPET) in patients with wild-type transthyretin cardiac amyloidosis treated with tafamidis is unknown.Methods and Results: This retrospective study included patients with wtATTR who underwent baseline cardiopulmonary exercise testing and were treated with tafamidis from August 31, 2018, until March 31, 2020. Univariate logistic and multivariate cox-regression models were used to predict the occurrence of the primary outcome (composite of mortality, heart transplant, and palliative inotrope initiation). A total of 33 patients were included (median age 82 years, interquartile range [IQR] 79-84 years), 84% were Caucasians and 79% were males). Majority of patients had New York Heart Association functional class III disease at baseline (67%). The baseline median peak oxygen consumption (VO2) and peak circulatory power (CP) were 11.35 mL/kg/min (IQR 8.5-14.2 mL/kg/min) and 1485.8 mm Hg/mL/min (IQR 988-2184 mm Hg/mL/min), respectively, the median ventilatory efficiency was 35.7 (IQR 31-41.2). After 1 year of follow-up, 11 patients experienced a primary end point. Upon multivariate analysis, the low peak VO2 (hazard ratio [HR] 0.43, 95% confidence interval [CI] 0.23-0.79, P = .007], peak CP (HR 0.98, 95% CI 0.98-0.99, P = .02), peak oxygen pulse (HR 0.62, 95% CI 0.39-0.97, P = .03), and exercise duration of less than 5.5 minutes (HR 5.82, 95% CI 1.29-26.2, P = .02) were significantly associated with the primary outcome.Conclusions: Tafamidis-treated patients with wtATTR who had baseline low peak VO2, peak CP, peak O2 pulse, and exercise duration of less than 5.5 minutes had worse outcomes. [ABSTRACT FROM AUTHOR]

Pericardial cysts are a rare disorder with an incidence of about 1 in 100,000, the majority of which are benign and incidentally identified. Pericardial cyst causing cardiac tamponade is an extremely rare phenomenon. The exact incidence of cardiac tamponade secondary to pericardial cyst is unknown. To the best of our knowledge limited case reports showing this association have been published. We have summarized cases showing this association in a tabular fashion. We present a case of a 36-year-old male who presented with symptoms of shortness of breath, chest pain, and fevers found to have ruptured pericardial cyst causing cardiac tamponade. < Learning objective: The majority of pericardial cysts are diagnosed incidentally and have benign course. Pericardial cyst causing cardiac tamponade is an extremely rare phenomenon. Ruptured pericardial cysts should be considered in the differential diagnosis of cardiac tamponade in patients with history of pericardial cyst. Interventions such as immediate pericardiocentesis, sternotomy, and surgical resection of cyst can be life-saving.> [ABSTRACT FROM AUTHOR]

Light Chain (AL) and transthyretin (ATTR) are the most common causes of amyloidosis related heart failure. Using the Nationwide Readmission Database, we retrospectively assessed adult patients (>18 years old) admitted with HF between 2018 to 2019. Baseline characteristics and clinical outcomes were compared between patients hospitalized with HF with underlying AL vs ATTR amyloidosis. Of 2,13,5057 HF hospitalizations, 782 (0.03%) had heart failure (HF) with a secondary diagnosis of AL and 568 (0.02) with ATTR. Patients with ATTR amyloidosis were mostly males (82 % vs 59%) and older (75.72±8.23 vs 67.87±8.75). ATTR amyloidosis patients had higher atrial fibrillation burden (63% vs 48%), kidney disease (67% vs 58%) and HTN (85 % vs 78%) (Table 1A). Using multivariate logistic regression, HF with ATTR amyloidosis showed lower inpatient mortality (1.05 % vs 5.43%, OR:0.13 (0.03-0.49), p=0.03). No significant difference was noticed in 30-day readmissions (25% vs 29%, HR:0.94, p=0.7). Most of the readmissions were due to cardiovascular causes in both groups (42 % vs 49 %, p= 0.5) and HF being the most common (29 vs 43%, p= 0.4) (Table 1B). In patients admitted with HF, ATTR amyloidosis was associated with lower inpatient mortality as compared to AL, but no significant difference was found in 30-day readmissions. [ABSTRACT FROM AUTHOR]

The incidence and prevalence rates of cardiac amyloidosis among hospitalized patients have increased in the last decade due to improved amyloidosis awareness and higher diagnostic rates with noninvasive imaging. Using the Nationwide Readmission Database, we retrospectively assessed adult patients (>18 years old) admitted with HF between 2016 to 2019. Baseline characteristics and clinical outcomes were compared between patients hospitalized with HF with and without underlying amyloidosis. Of 4,028,342 HF hospitalizations, 13732 (0.3%) had HF with a secondary diagnosis of amyloidosis. Patients with amyloidosis were mostly males (66% vs 52%) and older (73.55±12.26 vs 71.77±12.26). HF patients with amyloidosis had higher atrial fibrillation burden (54% vs 45%) and kidney disease (58% vs 44%). Diabetes and HTN were more common in patients without amyloidosis (Table 1). Using multivariate logistic regression and 1:3 matching, HF with amyloidosis showed higher inpatient mortality (4.18% vs 2.71%, OR:1.22 (1.04-1.44), p=0.013) and longer length of stay (7.63 ± 8.96 vs 5.42 ± 5.78, OR 1.95 (1.68-2.21), p= < 0.001). 30-day readmissions were higher in patients with amyloidosis (22% vs 20%, OR 1.14 (1.07-1.22), p= <0.001). Most of the readmissions were due to cardiovascular causes (50%) and HF being the most common (38%) (Fig1). In patients admitted with HF, presence of amyloidosis was associated with higher mortality, longer length of stay and higher 30-day readmissions. [ABSTRACT FROM AUTHOR]

Wild-type transthyretin amyloidosis (ATTRwt) is the most common form of transthyretin amyloid cardiomyopathy (ATTR-CM), occurring at a mean age of 80 years, with presentation under age 60 being rare. Early diagnosis is key to improving otherwise poor outcomes. A 58-years-old man with history of nonischemic cardiomyopathy (EF 15%-20%), implantable cardioverter defibrillator in situ, atrial fibrillation status post ablation, and prior left atrial thrombus presented with progressive heart failure (HF) symptoms despite maximum tolerated guideline directed medical therapy. He underwent right heart catheterization showing cardiogenic shock with CVP 18 mmHg, PA 43/25 with mean of 32, PCWP 23 mmHg, Fick cardiac output of 4.62 L/min, and cardiac index of 2.08 L/minute/m2. Transthoracic echocardiogram showed a reduced EF of 10%, concentric hypertrophy with interventricular septal thickness of 1.9 cm and posterior wall thickness of 1.4 cm (Figure 1A), moderately reduced RV function with a dilated RV, and moderate mitral regurgitation. A technetium pyrophosphate scan showed a heart/contralateral lung ratio of 1.77 and visual grade 3 highly suggestive of cardiac amyloidosis (Figure 1B). Cardiac magnetic resonance imaging showed global myocardial delayed hyperenhancement most likely due to cardiac amyloidosis. He was supported on milrinone until he underwent successful heart transplantation. The native heart tissue pathology showed amyloid deposits on Congo red staining. Liquid chromatography-tandem mass spectrometry was performed on the tissue and was consistent with ATTR-CM. The spectrometry did not detect an amino acid sequence abnormality in the transthyretin protein and genetic testing was performed and showed two genes of unknown significance, supporting ATTRwt as the final diagnosis. This is an unusual case of ATTR-CM presenting in a younger patient with end stage heart failure. Several new pharmaceutical therapies that target the disease at various levels have emerged, but are most effective when administered prior to significant cardiac dysfunction. Heart transplantation can be considered in patients with Stage D HF. The current allocation system provides priority as Status 4 to stage D ATTR-CM patients due to lack of durable mechanical support options. Physicians should consider ATTRwt in their differential for patients with HF, especially in non-ischemic cardiomyopathy patients with thickened interventricular septum, posterior wall thickness, and atrial fibrillation/arrythmia. Early diagnosis can be consequential in increasing patient quality of life and survival. [ABSTRACT FROM AUTHOR]

Obesity is the most common etiology of high output heart failure (HOHF). The difference in baseline characteristics and outcomes among obese patients with and without HOHF is not well known. This was a retrospective study including obese patients (BMI >35 kg/m2) from 1/1/2015 to 12/31/2019 at our center. We excluded patients with EF <45%, liver cirrhosis, arteriovenous fistula, heart transplant, and hemodialysis at time of right heart catheterization (baseline). Selected outcomes included all-cause mortality and heart failure readmissions. We included a total of 44 patients with HOHF (cases) and 97 patients without HOHF (controls). Mean age was 62 years in both groups. Majority of patients were females (77% vs 66%; p=0.18) and Caucasians (79% vs 81%; p=0.99) in cases vs controls, respectively. No significant difference in demographics, comorbidities, medications used and labs were noted among two groups (Table 1). The median baseline EF was 60% among both groups. By right heart catheterization, the median Cardiac Index by thermodilution method was 4.0 vs 2.98; p=<0.001 and by Fick method was 4.10 vs 2.96; p=<0.001 at baseline. No significant difference between right atrial (RA), right ventricular, pulmonary artery (PA) and wedge pressures were noted between cases and controls. PA saturation (74.5% vs 72%, p=0.0006) and RA saturation (76% vs 72%, p= <0.0001) were higher among cases. The patients were followed up for median of 31 (IQR=22.3-45.5) months. No significant difference in mortality (13.6% vs 10.3%, p=0.56) among both groups noted. Heart failure readmission rate was higher among cases compared to controls (40.9% vs 11.3%, p=<0.001). (Table 1) Obese patients with HOHF have higher heart failure readmission rate compared to obese patients without HOHF. There is no significant difference in baseline demographics and all-cause mortality among the two groups. [ABSTRACT FROM AUTHOR]

Epidemiology and outcomes of cardiogenic shock (CS) in patients with end stage renal disease (ESRD) have not been well studied. The objective of this study is to analyze temporal trends of incidence and outcomes of cardiogenic shock and utilization of percutaneous left ventricular assist device (pLVAD) in patients with ESRD. We identified all hospitalized patients with CS and ESRD between January 2006 to December 2018 utilizing the United States Renal Data System (USRDS) database. We analyzed trends in the incidence, use of mechanical circulatory support, in-hospital mortality, and 1-year all-cause mortality. There were a total of 38,679 patients with ESRD admitted for CS during the study period. Mean age was 67.8 years (IQR; 59.4, 75.9) and 59% were men. The annual incidence of CS in patients with ESRD increased from 0.27% to 0.57% from 2006 to 2018 (P trend <0.001) (Figure 1A). There was no significant change in in-hospital mortality (53.91% in 2006 and 41.41% in 2018; P trend =0.38) and 1-year all-cause mortality (28.91% in 2006 and 35.13% in 2017; P trend =0.1) during the study period (Figure 1B). There was decrease in the use of intra-aortic balloon pump from 17.86 % in 2006 to 8.25% in 2018 (P trend < 0.001) (Figure 1C) and a significant increasing trend in the use of Impella from 0.14% in 2006 to 4.8% in 2018 (P trend <0.001) (Figure 1D). On multivariable regression analysis, age, peripheral vascular disease (OR: 1.13, 95% CI: 1.08 to 1.18; p<0.0001), diabetes mellitus (OR: 1.11, 95% CI: 1.06 to 1.16; p<0.0001) and duration on dialysis are independent predictors of in-hospital mortality. The risk of CS increases with increasing duration on dialysis: time on dialysis 2-5 years (OR: 1.26, 95% CI: 1.20 to 1.32; p=0.02), 6-10 years (OR: 1.4, 95% CI: 1.32 to 1.5; p=0.003), and ≥11 years (OR: 1.69, 95% CI: 1.53 to 1.86; p<0.0001). The incidence of CS in patients with ESRD has doubled between 2006 and 2018. There has been significant decrease in use of IABP with concomitant increase in utilization of Impella during this period but there was no significant change in in-hospital and 1-year all-cause mortality. [ABSTRACT FROM AUTHOR]

The objective of this study was to characterize national estimates of emergency department (ED) presentations of patients with heart transplantation (HT) in the United States with a focus on demographic, clinical, and outcomes profile. The retrospective analysis of National Emergency Department Sample (NEDS) was performed. All ED visits of patients aged 18 years and older with International Classification of Diseases (ICD-10) code for HT from 2016 to 2018 were identified and analyzed. There were a total 55,583 ED visits (0.018 % of total ED visits) among adults with HT during the study period. The median age was 61.07 years (IQR: 46.91-69.38) and 69.44% of visits were among males. The most frequently diagnosed comorbid conditions were hypertension (66.1%), diabetes mellitus (41.63%), depression (11.06%), and ESRD on dialysis (9.59%). The hospital admission rate was 54.3% and median inpatient length of stay was 3.19 days (IQR: 1.63-5.92). The mortality rate during inpatient stay was 1.16%. Right and left heart catheterization was performed in 1.7% and 0.93% respectively. Median inpatient and ED charges among admitted patients were $37,911 (IQR: $21,487-$71262). The top 5 most common primary diagnosis of HT related ED visits were sepsis (4.3%), acute kidney injury (3.57%), unspecified chest pain (3%), and pneumonia (2.56%). More than half of total visits resulted in hospital admission. The most common causes for ED visit in this patient population were non cardiac reasons with sepsis being the most common primary diagnosis. The overall mortality related to ED visits and hospitalization remains low. [ABSTRACT FROM AUTHOR]

There is paucity of data regarding outcomes of stage D heart failure patients undergoing evaluation and treatment with advanced therapies [heart transplant (HTX), left ventricular assist device (LVAD)] in the setting of biopsy-proven liver fibrosis. We retrospectively assessed stage D heart failure patients (age>18 years) who had liver biopsy and underwent advanced therapy evaluation from 2017 to 2020. Overall baseline characteristics and 1-year clinical outcomes were compared between mild to moderate (stage 0-2) and severe liver fibrosis (stage 3-4) group. A total of 136 patients were included. HTX was done in 23 patients, LVAD in 48 patients and 65 did not undergo advance therapies (no therapy group). Patients in no therapy group were older (61 vs 55 vs 57 years; p =0.03) and had more diabetes (60% vs 26% vs 46%; p=0.02) in comparison to HTX and LVAD group, respectively. Whereas HTX group had more non-ischemic cardiomyopathy (83% vs 65% vs 43%; p=0.02) compared to LVAD and no therapy group, respectively (Table 1A). Steatohepatitis was present in 26.1% of HTX, 31.3% of LVAD and 32.3% in no therapy group. Biopsies identified 23 patients with severe liver fibrosis and 113 patients with mild to moderate fibrosis. 1 LVAD patient lost follow-up in mild to moderate fibrosis group. Out of 23 patients in severe fibrosis group, 65% underwent no advanced therapies, only 4% underwent HTX and 30% received LVAD (Table1B). Among patients in the no therapy group, mean PCWP was higher in fibrosis grade 3-4 when compared to fibrosis grade 0-2 group (23 vs 17, p= 0.04). No patient died in heart transplant group. There was no significant difference in 1-year mortality in LVAD group (43% vs 20%, p=0.2), whereas no therapy group showed high mortality (60% vs 26%, p=0.02) in severe fibrosis vs mild-moderate fibrosis patients (Tabe1B). The overall 1-year mortality among severe liver fibrosis patients who underwent no advanced therapy was 60% vs 37.5% with advanced therapies. Liver fibrosis is common among advanced heart failure patients. Mortality is high in end-stage heart failure patients with underlying severe liver fibrosis. As anticipated, patients with severe liver fibrosis were less likely to undergo LVAD or HTX than patients with mild to moderate fibrosis. Therefore, liver biopsy should be considered in patients being evaluated for advanced therapies. [ABSTRACT FROM AUTHOR]

There is paucity of data regarding Left ventricular Assist Device (LVAD) outcomes in patients with advanced Chronic kidney disease (CKD) and End Stage Renal Disease (ESRD). We conducted a retrospective study utilizing United States Renal Database (2006-2016) to compare 1-year outcomes between Medicare beneficiaries with ESRD to 5% sample of Medicare beneficiaries with CKD among LVAD patients. Comorbidities and outcomes were identified using appropriate ICD9 or ICD-10 codes. Patients who underwent heart transplant in follow up were excluded prior to obtaining outcomes. Subgroup analysis of CKD patients with available staging information [n=181(41.2%)] was explored to study CKD stage impact on outcomes. There were 482 patients with CKD and 192 patients with ESRD who underwent LVAD implantation. The ESRD group were 5 years younger and had more females compared to CKD group. Non-ischemic cardiomyopathy was more common in CKD vs ESRD (45.2% vs 23.9%, p <0.001). The details of baseline characteristics are shown in Table 1. The 1-year mortality is higher in ESRD when compared to CKD group (68.3% vs 35.5%, p <0.001). Median time to mortality in ESRD was 22 days (IQR; 6-55) and 46 days (IQR; 19-153) in CKD group. Out of patients with available baseline CKD staging, 91.2% had advanced CKD (stage III and above). Subgroup analysis in this cohort showed trend of increase in mortality from III (33.9%) to IV/V (40.9%). There were no significant differences in bleeding, pump thrombosis, stroke and sepsis/infection between two groups. The patients with ESRD who receive LVAD have worse survival when compared to CKD group. There is also trend of gradual increase in mortality with worsening renal function. This information will help in shared decision making while considering advance heart failure therapies in CKD or ESRD patients. [ABSTRACT FROM AUTHOR]

HeartMate 3 (HM3) and Heartware (HVAD) are the contemporary left ventricular assist device (LVAD) options with limited comparative data. We retrospectively included adult patients (>18 years) undergoing LVAD implantation at our center (Aug 2016 to Aug 2019). Overall baseline characteristics and major clinical outcomes were computed and compared using MOMENTUM 3 and ENDURANCE trial definitions. Subgroup analysis after propensity matching baseline characteristics and INTERMACS profile was also performed. A total of 93 patients were included, with six patients excluded as they died during the index implantation. Out of the remaining 87 patients, 33 (37.9%) had HM3 and 54 (62.1%) had HVAD. No significant difference in baseline characteristics were noted (Table 1A), except more patients with higher INTERMACS profile received HVAD (53.7% vs 27.3%; p=0.01). Device thrombosis and TIA/stroke were higher among HVAD patients (0 vs 18.5%; p = 0.009; 0 vs 11.1%: p=.04, respectively) (Table1B). No significant differences in overall mortality, GI bleeding, or driveline infections were noted. Propensity-matched cohort showed a higher rate of device thrombosis and TIA/stroke among HVAD (0 vs 13%: p = 0.07 and 0 vs 13%: p= 0.07, respectively) but was statistically non-significant (Table 1C). HVAD patients had higher thromboembolic complications, but no significant difference in other outcomes. Larger multicenter studies are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

HeartMate 3 (HM3) and HeartWare (HVAD) are the most commonly used centrifugal Left ventricular assist devices (LVAD) in the current era. Pump thrombosis is a serious adverse event in LVAD patients. The earliest reported case of HM3 pump thrombosis was on the 3rd-day post-implantation. We present a rare case of pump thrombosis within the first hour of implantation. 39-year-old male with non-ischemic cardiomyopathy (LVEF 20-25%) was referred to our center for advanced heart failure therapies. He was transferred on milrinone 0.25 mcg/kg/min and urgent right heart catheterization was performed: RA 12, PA 46/30 with mean of 30, PCWP 30 mmHg, CO 3.17 L/min and CI 1.5 L/min/m2. He was noted to be in cardiogenic shock with INTERMACS 2 profile. After multidisciplinary team discussion, urgent HM3 implantation was done. A thoracotomy and hemi-sternotomy approach was utilized. Before LVAD implantation, the LV cavity was examined and noted to be free of any clot. Heparin was reversed with standard protamine at the conclusion of cardiopulmonary bypass. No blood products or pro-coagulants were administered. Approximately 60 minutes after the end of the surgery, low flow alarms started. Intraoperative transesophageal echocardiogram was still in place and revealed no pericardial effusion or tamponade. Maneuvers including ramping speed and increasing dose of inotropes had no effect; the patient's right ventricular function was adequate, but his aortic valve could not be closed. After sternal reopening, the absence of tamponade was confirmed and there was no kinking of the outflow graft. Given the acute persistent drop in pump flow despite the above corrective measures, there was a strong suspicion of pump thrombosis. Patient's chest was re-opened. The pump was unlocked from the sewing ring and inspected. The inflow cannula had fresh, nearly occlusive thrombus present (Figure 1). Thrombus involved all centered surfaces and also the outflow side of the pump. Pump exchange without reversal of heparin was performed. The pump was sent to the manufacturer for inspection. Histological analysis confirmed the pump thrombus. The patient's subsequent hypercoagulable workup was negative. This case represents a unique instance of a very early pump thrombosis and should be kept in mind if new, low flow alarms are encountered immediately post-implant. [ABSTRACT FROM AUTHOR]

The use of Extracorporeal Membrane Oxygenation (ECMO) for cardiogenic shock has been increasing in the United States and is associated with significant morbidity, mortality, and healthcare resources utilization. We sought to explore rates and predictors of hospital readmissions in patients with cardiogenic shock after contemporary ECMO use. Using the Nationwide Readmission Database, we included adult patients (≥18 years old) who were hospitalized between January to November between 2016-2018 for cardiogenic shock (ICD code R57.0) requiring ECMO support (ICD-10-PCS 5A15223). Thirty-day readmission rates, associated variables, and predictors of readmission were assessed. A total of 10,723 patients underwent ECMO for cardiogenic shock from 2016 to 2018. After excluding patients who died (n=5,602; 52%) and those who underwent LVAD or OHT during index admission (n=892; 8%), 4,229 patients discharged alive were included in our analysis. Of those, 694 (16.4%) were re-admitted within 30 days. The median time to readmission was 10 days. Diabetes mellitus (OR=1.77; 95% CI 1.32-2.37), chronic liver disease (OR=1.35; 95% CI 1.03-1.77), and prolonged LOS (≥30 days; OR =1.38; 95% CI 1.05-1.81) were associated with increased risk of 30-day readmissions while heart failure diagnosis (OR = 0.69; 95% CI 0.50-0.95) and short-term hospital post discharge care (OR = 0.53; 95% CI 0.28-0.99) conferred a lower risk. Sepsis, followed by congestive heart failure were the more common causes for readmission. Proper identification of patients at increased risk for readmission may help improve prevention strategies and improve outcomes of cardiogenic shock after ECMO. [ABSTRACT FROM AUTHOR]

Prognostic value of cardiopulmonary exercise test (CPET) in heart failure with reduced ejection fraction is well established, but it's utility in wild type transthyretin cardiac amyloidosis (wtATTR) patients treated with Tafamidis is unknown. To determine the role of baseline CPET in Tafamidis treated wtATTR amyloid patients. A retrospective study was conducted to identify wtATTR patients who were treated with Tafamidis and underwent baseline CPET at The University of Kansas Amyloid Clinic from 8/31/2018 until 3/31/2020. Univariate and multivariate logistic regression models were used to predict the occurrence of the primary outcome (composite of mortality, heart transplant, and palliative inotrope initiation). A total of 33 patients were included with a mean age of 81 ± 5.7 years. About 84% were Caucasians and 79% were males. Mean peak oxygen consumption (VO 2) and peak circulatory power (CP) were low at 11.88 ± 3.74 ml/kg/min and 1667.8 ± 804.2 mmHg/ml/min, respectively. Mean VE/VCO 2 (Ventilatory efficiency) was 36.65 ± 8.7. After 1 year follow-up, 11 patients had reached the primary outcome. Median exercise duration was significantly lower in patients with primary outcomes compared to those without as shown in figure 1 [4.4 (IQR 3.6-4.7) vs 6.9 (IQR 5.9-8.9), p <0.001]. Upon multivariate analysis; peak VO 2 [OR 0.25, CI(0.07-0.91), p=0.03], peak CP [OR 0.99,CI(0.98-0.99), p=0.03] and peak VO 2 /HR (Oxygen pulse) [OR 0.44, CI(0.22-0.87), p=0.02] were significantly associated with the primary outcome. VE/VC0 2 (Ventilatory efficiency) was not significantly associated with the primary outcome. (Table 1) Peak V02, peak CP, and peak VO 2 /HR may have a prognostic role in selecting which wtATTR patients will benefit from Tafamidis treatment. [ABSTRACT FROM AUTHOR]

Significant therapeutic advancements including guideline-directed-therapy (GDMT) and device implantation have improved outcomes in heart failure patients. Their impact on patients with advanced heart failure requiring chronic inotropic support who are not candidates for left ventricular assist device (LVAD) or heart transplant (HT) is not well studied. We aimed to study outcomes in these patients discharged on inotropes while comparing the dobutamine and milrinone cohorts. We conducted a retrospective multi-center study from Jan 2015 to May 2019. A total of 249 patients who were hospitalized with refractory stage-D heart failure and discharged on continuous long-term milrinone or dobutamine therapy were included. Patients who were candidates for HT or LVAD and those discharged on comfort measures were excluded. Multivariable logistic regression was utilized to assess odds of mortality in these patients. Overall mean age was 64.8 ±13.4 years. Majority of the patients were males, Caucasian and had a pre-implanted cardiac device. Common comorbidities included CAD, diabetes, hypertension and CKD. Age and baseline comorbidities were similar in both groups except for CKD which was more prevalent in dobutamine group (59.4 vs 52.0; p-value=0.02). Overall, mean baseline Ejection Fraction was 20.2%, similar in both groups (p=0.71). Patients on dobutamine had higher baseline cardiac indices than milrinone group (Fick 2.0 vs 1.8; p-value=0.048, Thermodilution 2.0 vs 1.6; p-value=0.002). Overall, 1-year mortality was 70.7 %. Patients on milrinone had lower 1-year-mortality compared to dobutamine group (58.1% vs 85.0%; P-value<0.01). Unadjusted odds ratio (OR) for milrinone group was 0.24 (CI 0.13-0.46, p-value=p<0.001). When adjusted for age, sex, race and BMI, OR was 0.29 (CI 0.15-0.58, p-value=0.001). Milrinone cohort had more patients discharged on beta blocker (42.9 vs 8.6; p-value <0.001). Other GDMT was also more common on discharge in milrinone group, though statistical significance was not reached. Six patients became candidates for advanced therapies (LVAD/HT). (See Table) Mortality remains high in patients started on chronic inotropes who are not candidates for LVAD/HT. Milrinone may have better patient outcomes as compared to dobutamine but larger comparative controlled studies are needed to confirm this. [ABSTRACT FROM AUTHOR]

Benefits of temporary mechanical circulatory support has not been demonstrated successfully in clinical trials despite their increased widespread use in the real-world management of patients with cardiogenic shock (CS). Using the Nationwide Readmissions Database from Jan 2016 to Nov 2017, we identified all patients admitted with CS requiring either only intra-aortic balloon pump (IABP) or Impella device implantation (IM) with 30-day follow up. Patients with combined devices or undergoing medical management only were excluded. Propensity matched (1:1) was performed based on demographics and comorbidities to compare the survival, complications, and use of advanced heart failure therapies. Out of a total of 236156 patients, 32850(13.9%) had IABP and 8389(3.5%; unweighted n= 4504) patients had IM implantation. Well-matched 4411-pairs of matched IABP vs IM patients had mean similar age (65 vs 64.9 years), women (29.2% vs 28.6%), and acute myocardial infarction (75.7% vs 75.8%). In terms of therapy, no differences in use of right heart catheterization/pulmonary catheter placement or vasopressor use(p>0.05 for all). IM group had higher mortality (45.8% vs. 28.6%, p <0.001) with increased rates of acute kidney injury with no differences in ischemic strokes/major bleeding needing blood transfusion. Overall, the 30-day readmission rate was ≈19% with no intergroup differences. IABP patients had higher rates heart transplant compared to IM group- with no difference in bridging to left ventricular assist device. Significant number of CS patients undergo IM implantations with widely different survival as well as candidacy for a heart transplant. The underlying patient- and physician-related differences need to further be explored prior to widespread use of this powerful technology. [ABSTRACT FROM AUTHOR]

Background: The usefulness of the Right Heart Catherization/Pulmonary Artery Catheterization (RHC/PAC) has been long debated. Previous evidence has shown the lack of additive benefit of RHC/PAC use in various clinical settings. However, current evidence of RHC/PAC utility in the setting of cardiogenic shock (CS) is scarce. Methods: In the Nationwide Readmissions Database (NRD) using International Classification of Diseases, Tenth revision we identified 269,475 patient hospitalizations with cardiogenic shock between 2016-2017. We sought to evaluate the impact of RHC/PAC on in-hospital and readmission outcomes. Results: Approximately 25,840 patients received a RHC/PAC on index admission. The RHC/PAC group had significantly more comorbidities and higher AKI rates (73% vs 60.4%; p<0.001) but lower death (25.8% vs 39.5%; p<0.001) and stroke rates (3.4% vs 3.1%; p<0.001) during index admission. Readmission rates (18.7% vs19.7%; p=0.04) and death on readmission (7.9% vs 9.3%; p=0.03) were lower in the RHC/PAC group. RHC/PAC was independently associated with lower mortality (OR=0.67, 95% CI 0.64-0.70; p<0.001), increased use of mechanical circulatory support (MCS; OR=2.62, 95% CI 2.50-2.74 p<0.001) and left ventricular assist device/heart transplant (LVAD/OHT; OR=5.27, 95% CI 4.88-5.70; p<0.001) during index admission. RHC/PAC was an independent predictor of lower readmission rates (OR=0.81, 95 CI 0.77-0.86; p<0.001), increased MCS use (OR=2.27, 95% CI 1.72-2.96; p<0.001) and LVAD/OHT use (OR=5.82, 95% CI 4.27-7.94; p<0.001) during rehospitalization (Figure 1). Conclusions: The RHC/PAC use in CS is associated with improved outcomes, and increased use of MCS and LVAD/OHT. Further blinded randomized studies are required to confirm our findings. [ABSTRACT FROM AUTHOR]

Arrhythmogenic Right Ventricular Dysplasia (ARVD) is inherited cardiomyopathy with an estimated prevalence of 1 in 5000 people. 20 years old male with no PMH had out of hospital cardiac arrest while playing basketball. Bystander CPR was started immediately, and ROSC was achieved after 2 shocks for Vfib. He was intubated immediately on arrival at the nearest ER. A bedside echo showed biventricular failure with LVEF of 5-10%. The patient was taken for an urgent LHC that showed normal coronary arteries. An IABP was placed and he was transferred to our hospital for advanced heart failure therapies. Physical examination was remarkable for intubated and sedated patient with no JVD, and extremities were warm to touch. EKG showed normal sinus rhythm with T wave inversions in V1-V3 lead, normal QTc (Figure 1). He underwent emergent RHC with endomyocardial biopsy which showed RA of 18 mmHg, RV of 36/14 mmHg, PA of 33/18 mmHg, PCWP of 20 mmHg, CO/CI of 2.52/1.24 and PA sat of 48%. Cardiogenic shock conference was initiated, and the decision was made to proceed with VA-ECMO. The biopsy showed inflammatory infiltrate including macrophages, neutrophils, T cells, and focal associated myocyte damage but no giant cells or lymphoid aggregates (Figure 1). This was concerning for acute fulminant myocarditis vs another inflammatory process. He started showing signs of hemodynamic and echocardiographic recovery on day 2 without requiring immunosuppressive medications. VA-ECMO was decannulated on day 3 and extubated on day 4. He was diagnosed as myocarditis and discharged on day 7 with full LVEF recovery but RV remained dilated with reduced function. A cardiac MRI done 1 week later ruled out myocarditis. On follow up visit one month later, he is asymptomatic. His echo shows dyskinetic and dilated RV with PLAX RVOT of 33 mm with normal LV (Figure 1). Genetic testing showed PKP2 mutation. Hence, the diagnosis was ultimately modified to ARVD. He is now referred for an ICD implantation and advised abstinence from competitive sports. ARVD presents a diagnostic challenge since diseases like myocarditis, sarcoidosis, and dilated cardiomyopathy can act as mimics. Our patient met three major criteria from the 2010 International Task Force Guidelines, including EKG, echo, and genetic mutation; hence meeting requirements for definitive diagnosis of ARVD. ARVD can lead to sudden cardiac death due to ventricular electrical instability. ARVD poses diagnostic challenge, a high index of clinical suspicion is required. Initially, ARVD can present similarly to myocarditis on histopathology. VA-ECMO can be utilized as bridge to recovery in critically ill patients with ARVD. [ABSTRACT FROM AUTHOR]