Search

Objective: Biaxial mechanical testing is a common method for elucidation of mechanical properties of excised ventricular myocardium, especially in the context of structural remodeling that accompanies heart disease. Current imaging strategies in biaxial testing are based on optical camera imaging of the tissue surface, thus providing no information about the tissue microstructure and limiting strain measurements to two dimensions. Here, these limitations are overcome by replacing the camera with ultrasound imaging in order to measure both transmural fiber orientation and 3D tissue deformation during biaxial testing. Methods: Quasi-static biaxial mechanical testing is applied to four samples of excised porcine ventricular myocardium (two left- and two right-ventricular tissues). During testing, a rotational scan of an ultrasound linear array provides data for both backscatter tensor imaging and 3D speckle tracking, from which transmural fiber orientation and tissue deformation are computed, respectively. Ultrasound-derived fiber orientation and tissue strain are validated against histology and camera surface imaging, respectively. Discussion: Ultrasound-derived fiber angle and tissue strain exhibit good accuracy, with root-mean-square errors of 9.9° and 1.2% strain, respectively. Further investigation into the optimization of backscatter tensor imaging is warranted. Replacing the rotational scan of a linear array with volume imaging with a matrix array will improve the technique. Conclusion: Ultrasound imaging can replace the optical camera measurement during biaxial mechanical testing of ventricular myocardium in order to accurately provide measurements of transmural fiber orientation and tissue strain. In situ knowledge of transmural fiber structure and tissue deformation can enhance the inverse problem used to determine tissue mechanical properties from biaxial testing. [ABSTRACT FROM AUTHOR]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2010.01.004 Byline: Marc A. Simon, Dustin E. Kliner, John P. Girod, Diego Moguillansky, Flordeliza S. Villanueva, John J. Pacella Abstract: Accurate assessment of right atrial pressure (RAP) often requires invasive measurement. With normal RAP, Valsalva increases right internal jugular vein (RIJV) cross sectional area (CSA) 20% to 30%. With high RAP, when venous compliance is low, we hypothesized that the increase in CSA would be blunted and could be detected non-invasively with bedside ultrasound. Author Affiliation: Center for Ultrasound Molecular Imaging and Therapeutics, Cardiovascular Institute, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA Article History: Received 21 July 2009; Accepted 6 January 2010

Background: Few data are available on the use of internal jugular vein (IJV) ultrasound parameters to assess central venous pressure and clinical outcomes among patients with suspected or confirmed heart failure (HF).Methods: We performed electronic searches on PubMed, The Cochrane Library, EMBASE, EBSCO, Web of Science, and CINAHL databases from the inception through January 9, 2021, to identify studies evaluating the accuracy and reliability of the IJV ultrasound parameters and exploring its correlation with central venous pressure and clinical outcomes in adult patients with suspected or confirmed acutely decompensated HF. The studies' report quality was assessed by Quality Assessment of Diagnostic Accuracy Studies-2 scale.Results: A total of 11 studies were eligible for final analysis (n = 1481 patients with HF). The studies were segregated into 3 groups: (1) the evaluation of patients presenting to the emergency department with dyspnea, (2) the evaluation of patients presenting to the HF clinic for follow-up, and (3) the evaluation of hospitalized patients with acutely decompensated HF or undergoing right heart catheterization. US parameters included IJV height, IJV diameter, IJV diameter ratio, IJV cross-sectional area, respiratory compressibility index, and compression compressibility index.Conclusions: The findings of this systematic review suggest a significant role for ultrasound interrogation of the IJV in evaluation of patients in the emergency department presenting with dyspnea, in the outpatient clinic for poor clinical outcomes in HF, and in determining the timing of discharge for patients admitted with acutely decompensated HF. Further studies are warranted for testing the reliability of the reported ultrasound indices. [ABSTRACT FROM AUTHOR]

Background: In PARADIGM-HF, sacubitril/valsartan improved quality of life (QOL) versus enalapril in heart failure with reduced ejection fraction (HFrEF), yet limited data are available regarding QOL changes after sacubitril/valsartan initiation in routine practice.Methods: PROVIDE-HF was a prospective study within a national research network (Patient-Centered Outcomes Research Network) of HFrEF outpatients recently initiated on sacubitril/valsartan versus controls with recent angiotensin-converting enzyme inhibitor/angiotensin receptor blocker initiation/dose change. The primary end point was mean Kansas City Cardiomyopathy Questionnaire (KCCQ) change through 12 weeks. Other end points included responder analyses: ≥5-point and ≥20-point KCCQ increase. Adjusted QOL change was estimated after propensity score weighting.Results: Overall, 270 patients had both baseline and 12-week KCCQ data (151 sacubitril/valsartan; 119 control). The groups had similar demographics and HF details: median EF 28% and N-terminal pro-brain natriuretic peptide 1083 pg/mL. Sacubitril/valsartan patients had larger improvements in KCCQ (mean difference +4.76; P = .027) and were more likely to have a ≥5-point and ≥20-point response (all P < .05). Adjusted comparisons demonstrated similar numerical improvements in the change in KCCQ (+4.55; 95% CI -0.89 to 9.99; P = .101) and likelihood of ≥5-point increase (odds ratio 1.55; 95% CI: 0.84-2.86; P = .16); ≥20-point increase remained statistically significant (odds ratio 3.79; 95% CI 1.47-9.73; P = .006).Conclusions: In this prospective HFrEF study of sacubitril/valsartan initiation compared with recent angiotensin-converting enzyme inhibitor/angiotensin receptor blocker initiation/dose change, the between-group difference in the primary end point, mean KCCQ change at 12 weeks was not statistically significant following adjustment, but sacubitril/valsartan initiation was associated with early improvements in QOL and a higher likelihood of ≥20-point improvement in KCCQ at 12 weeks. These data add additional real-world evidence related to patient-reported outcomes following the initiation of sacubitril/valsartan in routine clinical practice. [ABSTRACT FROM AUTHOR]

Background: The severity of pulmonary hypertension (PH) is monitored by measuring pulmonary vascular resistance, which is a steady-state measurement and ignores the pulsatile load encountered by the right ventricle (RV). Pulmonary vascular impedance (PVZ) can depict both steady-state and pulsatile forces, and thus may better predict clinical outcomes. We sought to calculate PVZ in patients with PH associated with heart failure with preserved ejection fraction who were administered inhaled sodium nitrite to better understand the acute effects on afterload.Methods and Results: Fourteen patients with PH associated with heart failure with preserved ejection fraction underwent right heart catherization and were administered inhaled sodium nitrite. A Fourier transform was used to calculate PVZ for both before and after nitrite for comparison. Inhaled sodium nitrite decreased characteristic impedance (inversely related to proximal pulmonary artery compliance) and total work performed by the RV. RV efficiency improved, defined by a reduction in the total work divided by cardiac output. There was a mild decrease in pulmonary steady-state resistance after the administration of inhaled sodium nitrite, but this effect was not significant.Conclusions: PVZ analysis showed administration of inhaled sodium nitrite was associated with an improvement in pulmonary vascular compliance via a decrease in characteristic impedance, more so than pulmonary steady-state resistance. This effect was associated with improved RV efficiency and total work. [ABSTRACT FROM AUTHOR]

Beta-blockers (BB) have a significant mortality benefit in heart failure with reduced ejection fraction (HFrEF) but the evidence regarding their benefit in heart failure with preserved ejection fraction (HFpEF) remains inconclusive. HFpEF incidence is increasing with rising morbidity and mortality. Moreover, treatment options are limited because many clinical trials of potential pharmacologic therapy have shown neutral or negative results. This lack of conclusive evidence for BB benefit has led to a practice of BB withdrawal in this population. In this study, we retrospectively analyzed the effect of BB on all-cause mortality in HFpEF patients. This is a single center retrospective cohort study of inpatients with ejection fraction (EF) ≥ 50% who were admitted with HFpEF exacerbation between January 2011 and March 2020. Cox proportional-hazards models are used to compute hazard ratios for BB versus non-BB groups for each endpoint. Charlson Deyo comorbidity scores were used to stratify patients. Survival is reported using Kaplan-Meier curves at 30 days and 1 year; A secondary analysis comparing all-cause mortality for patients on BB with additional indications for BB was completed including hypertension (HTN), coronary artery disease (CAD) and atrial fibrillation (AF). All-cause mortality was also compared between patients on BB and additional therapies of spironolactone or Angiotensin-converting-enzyme inhibitors/Angiotensin receptor blockers (ACEi/ARBs) Among patients with EF ≥ 50%, BB showed reduced all-cause mortality at 30 days and 12 months. In a secondary analysis, there was significant reduction in mortality for patients on BB and ACEi/ARB vs. those on only ACEi/ARB as well as BB and spironolactone vs. spironolactone only at 3 years. There was no reduction of mortality for patients with CAD, HTN, or AF at 1 year (Figure 1). Beta-blocker use in HF patients regardless of EF showed significant survival advantage. This benefit is not driven by the presence of CAD, HTN or AF. [ABSTRACT FROM AUTHOR]

Appendicitis in the infant population is rare and often misdiagnosed. It can be associated with perforation and sepsis and necessitates expedient identification when present in a sick infant. We describe a case of perforated appendicitis in a 10-month-old infant after diagnostic workup ruled out common causes of colicky abdominal pain. We highlight documented recommendations for workup and management of neonatal and infantile appendicitis. We show that the consensus in literature is prompt diagnosis and surgical intervention for the best chance at preventing morbid outcomes that increase mortality. [ABSTRACT FROM AUTHOR]

Copyright of Archives of Cardiovascular Diseases is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

An implementation of the independent component analysis (ICA) technique for three-dimensional (3D) statistical shape analysis is presented. The capabilities of the ICA approach to uncover inherent shape features are first demonstrated through analysis of sets of artificially generated surfaces, and the nature of these features is compared to a more traditional proper orthogonal decomposition (POD) technique. For the surfaces generated, the ICA approach is shown to consistently extract surface features that closely resembled the original basis surfaces used to generate the artificial dataset, while the POD approach produces features that clearly mix the original basis. The details of an implementation of the ICA approach within a statistical shape analysis framework are then presented. Results are shown for the ICA decomposition of a collection of clinically obtained human right ventricle endocardial surfaces (RVES) segmented from cardiac computed tomography imaging, and these results are again compared with an analogous statistical shape analysis framework utilizing POD in lieu of ICA. The ICA approach is shown to produce shape features for the RVES that capture more localized variations in the shape across the set compared to the POD approach, and overall, the ICA approach produces features that represent the RVES variation throughout the set in a considerably different manner than the more traditional POD approach, providing a potentially useful alternate to statistically analyze such a set of shapes. [ABSTRACT FROM AUTHOR]

Background: HIV-infected individuals are at increased risk for pulmonary hypertension and cardiomyopathy, portending a poor prognosis. Right ventricular (RV) dysfunction is associated with worse outcomes in these conditions, yet its prevalence is poorly defined in HIV. We sought to determine the prevalence of RV dysfunction in an outpatient HIV cohort. Methods: Echocardiograms were evaluated from 104 HIV-infected adults. Measurements included estimated pulmonary arterial systolic pressure (PASP) and several measures of RV function, including tricuspid annular plane systolic excursion (TAPSE), RV longitudinal myocardial strain (RVLMS), RV fractional area change (RVFAC), and myocardial performance index (MPI). Results: Sixteen subjects (15%) had PASP > 35 mm Hg, yet RV function did not differ significantly from those with normal estimated PASR RV dysfunction defined by RVFAC < 35% occurred in 11%. RVLMS had a median value of -27.3%, and individuals below the median had lower TAPSE but no differences in left ventricular ejection fraction (LVEF), PASP, or other measures. Dyspnea was associated with the lowest quintile of RVLMS (≥ -21.05%). There were 6 subjects with LVEF <50%, and these individuals had lower TAPSE but no differences in PASP or other RV functional measures. Conclusions: RV dysfunction was common as estimated PASP > 35 mm Hg and LV dysfunction, but these findings did not cosegregate. RV dysfunction in HIV-infected individuals may be a separate entity from LV/global cardiomyopathy or pulmonary hypertension and deserves further study. [ABSTRACT FROM AUTHOR]

Background: Echocardiography (echo) is a first line test to assess cardiac structure and function. It is not known if cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE) ordered during routine clinical practice in selected patients can add additional prognostic information after routine echo. We assessed whether CMR improves outcomes prediction after contemporaneous echo, which may have implications for efforts to optimize processes of care, assess effectiveness, and allocate limited health care resources. Methods and results: We prospectively enrolled 1044 consecutive patients referred for CMR. There were 38 deaths and 3 cardiac transplants over a median follow-up of 1.0 years (IQR 0.4-1.5). We first reproduced previous survival curve strata (presence of LGE and ejection fraction (EF) < 50%) for transplant free survival, to support generalizability of any findings. Then, in a subset (n = 444) with contemporaneous echo (median 3 days apart, IQR 1-9), EF by echo (assessed visually) or CMR were modestly correlated (R2 = 0.66, p < 0.001), and 30 deaths and 3 transplants occurred over a median follow-up of 0.83 years (IQR 0.29-1.40). CMR EF predicted mortality better than echo EF in univariable Cox models (Integrated Discrimination Improvement (IDI) 0.018, 95% CI 0.008-0.034; Net Reclassification Improvement (NRI) 0.51, 95% CI 0.11-0.85). Finally, LGE further improved prediction beyond EF as determined by hazard ratios, NRI, and IDI in all Cox models predicting mortality or transplant free survival, adjusting for age, gender, wall motion, and EF. Conclusions: Among those referred for CMR after echocardiography, CMR with LGE further improves risk stratification of individuals at risk for death or death/cardiac transplant. [ABSTRACT FROM AUTHOR]

Copyright of Archives of Cardiovascular Diseases is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Right ventricular (RV) failure is a significant complication after implantation of a left ventricular assist device (LVAD). It is therefore important to identify patients at risk a priori. However, prognostic models derived from multivariate analyses have had limited predictive power. Methods: This study retrospectively analyzed the records of 183 LVAD recipients between May 1996 and October 2009; of these, 27 later required a RVAD (RVAD+) and 156 remained on LVAD only (RVAD − ) until transplant or death. A decision tree model was constructed to represent combinatorial non-linear relationships of the pre-operative data that are predictive of the need for RVAD support. Results: An optimal set of 8 pre-operative variables were identified: transpulmonary gradient, age, right atrial pressure, international normalized ratio, heart rate, white blood cell count, alanine aminotransferase, and the number of inotropic agents. The resultant decision tree, which consisted of 28 branches and 15 leaves, identified RVAD+ patients with 85% sensitivity, RVAD − patients with 83% specificity, and exhibited an area under the receiver operating characteristic curve of 0.87. Conclusions: The decision tree model developed in this study exhibited several advantages compared with existing risk scores. Quantitatively, it provided improved prognosis of RV support by encoding the non-linear, synergic interactions among pre-operative variables. Because of its intuitive structure, it more closely mimics clinical reasoning and therefore can be more readily interpreted. Further development with additional multicenter, longitudinal data may provide a valuable prognostic tool for triage of LVAD therapy and, potentially, improve outcomes. [ABSTRACT FROM AUTHOR]

Background: Implantable cardioverter-defibrillators (ICDs) reduce mortality in heart failure (HF). In patients requiring a ventricular assist device (VAD), the benefit from ICD therapy is not well established. The aim of this study was to define the impact of ICD on outcomes in VAD-supported patients.Methods and Results: We reviewed data for consecutive adult HF patients receiving VAD as a bridge to transplantation from 1996 to 2003. The primary outcome was survival to transplantation. A total of 144 VADs were implanted [85 left ventricular (LVAD), 59 biventricular (BIVAD), mean age 50 ± 12 years, 77% male, left ventricular ejection fraction 18 ± 9%, 54% ischemic]. Mean length of support was 119 days (range 1-670); 103 patients (72%) survived to transplantation. Forty-five patients had an ICD (33 LVAD, 12 BIVAD). More LVAD patients had an appropriate ICD shock before implantation than after (16 vs 7; P = .02). There was a trend toward higher shock frequency before LVAD implant than after (3.3 ± 5.2 vs 1.1 ± 3.8 shocks/y; P = .06). Mean time to first shock after VAD implant was 129 ± 109 days. LVAD-supported patients with an ICD were significantly more likely to survive to transplantation [1-y actuarial survival to transplantation: LVAD: 91% with ICD vs 57% without ICD (log-rank P = .01); BIVAD: 54% vs 47% (log-rank P = NS)]. An ICD was associated with significantly increased survival in a multivariate model controlling for confounding variables (odds ratio 2.54, 95% confidence interval 1.04-6.21; P = .04).Conclusions: Shock frequency decreases after VAD implantation, likely owing to ventricular unloading, but appropriate ICD shocks still occur in 21% of patients. An ICD is associated with improved survival in LVAD-supported HF patients. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to evaluate mechanical dyssynchrony in patients with acute onset cardiomyopathy with narrow QRS interval, and its association with improvements in left ventricular (LV) function. Background: LV dyssynchrony has been usually studied in patients with chronic heart failure and wide QRS in the context of cardiac resynchronization therapy. Methods: We studied 201 patients enrolled in the IMAC-2 (Inflammatory Mediators in Acute Cardiomyopathy) trial with recent onset nonischemic cardiomyopathy and ejection fraction <40%. Dyssynchrony was assessed using speckle-tracking velocity vector imaging. Diastolic function was assessed by mitral inflow E and mitral E'' annular velocities (E/E''). A normal control group of 15 normal volunteers was studied for comparison. Results: Although mean QRS was narrow (98 ± 21 ms), 108 (54%) acute cardiomyopathy patients had significant LV dyssynchrony at presentation: opposing wall delay 89 ± 51 ms, versus 35 ± 11 ms in controls, and 12-site standard deviation 43 ± 23, versus 24 ± 8 ms in controls (p < 0.001). Patients with dyssynchrony had greater degrees of diastolic dysfunction: E/E'' 15 ± 8 versus 12 ± 6 (p < 0.05). At 6 months, group mean ejection fraction improved from 23 ± 8% to 40 ± 12% and E/E'' improved from 14 ± 7 to 9 ± 5 (both p < 0.001). Dyssynchrony improved from 89 ± 51 ms to 52 ± 35 ms in maximum opposing wall delay, and 43 ± 23 ms to 32 ± 19 ms in 12-site standard deviation, and the prevalence of dyssynchrony decreased to 12% after 6 months (p < 0.001 vs. baseline). Conclusions: Mechanical dyssynchrony was observed in a significant number of patients with acute onset cardiomyopathy, despite having a narrow QRS interval. Resolution of dyssynchrony associated with improvements in LV function occurred in the large majority of these patients. [Copyright &y& Elsevier]

Background: Renal dysfunction is common before mechanical circulatory support (MCS). Mechanical circulatory support frequently improves renal function, but the impact of pre-MCS renal dysfunction on renal function after cardiac transplantation (CTX) is unknown. Methods: Patients with MCS from January 1995 until April 2008 at a single center were included if their MCS duration was at least 60 days and they underwent successful CTX. Patients were followed for 1 year after CTX. Results: A total of 116 patients were included in the study. Mechanical circulatory support was biventricular assist device in 28% and left ventricular assist device in 72% (continuous flow left ventricular assist device, 14%). Mean duration of MCS was 124 days. Patients were grouped according to tertiles of pre-MCS creatinine clearance (CrCl): group 1, CrCl less than 45 mL/min; group 2, CrCl between 45 and 65 mL/min inclusive; and group 3, CrCl more than 65 mL/min. Group 3 had the best renal outcomes both after MCS and 1 year after CTX. Regardless of group, patients who had a CrCl of at least 60 mL/min before CTX had similar 1-year posttransplant CrCl (55 versus 53 versus 56 mL/min for groups 1 through 3, respectively; not significantly different). However, the ability to achieve this level of renal function after MCS was less likely in those with the worst renal function before the initiation of MCS (53% versus 74% versus 90% for groups 1 through 3, respectively; p = 0.001). Conclusions: The use of MCS leads to improvements in renal function in patients after MCS. However, the renal outcomes after CTX seem to be more dependent on the level of renal function achieved during MCS than on the level of renal function before MCS. [Copyright &y& Elsevier]

Abstract: Background: Outcomes among inotrope-treated heart failure (HF) patients receiving cardiac resynchronization therapy (CRT) have not been well characterized, particularly in those requiring intravenous inotropes at the time of implant. Methods: We analyzed 759 consecutive CRT-defibrillator recipients who were categorized as never on inotropes (NI; n = 585), weaned from inotropes before implant (PI; n = 124), or on inotropes at implant (II; n = 50). Survival free from heart transplant or ventricular assist device and overall survival were compared using the Social Security Death Index. A patient cohort who underwent unsuccessful CRT implantation and received a standard defibrillator (SD; n = 94) comprised a comparison group. Propensity score analysis was used to control for intergroup baseline differences. Results: Compared with the other cohorts, II patients had more comorbidities. Both survival endpoints differed significantly (P < .001) among the 4 cohorts; II patients demonstrated shorter survival than NI patients, with the PI and SD groups having intermediate survival. After adjusting for propensity scores, overall differences and patterns in survival endpoints persisted (P < .01), but the only statistically significant pairwise difference was overall survival between the NI and II groups at 12 months (hazard ratio 2.95, 95% confidence interval 1.05-8.35). CRT recipients ever on inotropes (PI and II) and SD patients ever requiring inotropes (n = 17) experienced similar survival endpoints. Among II patients, predictors of hospital discharge free from inotropes after CRT included male gender, older age, and ability to tolerate β-blockade. Conclusions: Inotrope-dependent HF patients show significantly worse survival despite CRT than inotrope-naïve patients, in part because of more comorbid conditions at baseline. CRT may not provide a survival advantage over a standard defibrillator among patients who have received inotropes before CRT. Weaning from inotropes and initiating neurohormonal antagonists before CRT should be an important goal among inotrope-dependent HF patients. [Copyright &y& Elsevier]

Abstract: Background: Myocardial recovery after ventricular assist devices (VAD) is rare but appears more common in nonischemic cardiomyopathies (NICM). We sought to evaluate left ventricular (LV) end diastolic diameter (LVEDD) for predicting recovery after VAD. Methods and Results: NICM patients receiving long-term mechanical support between 1996 and 2008 were reviewed. Subjects were divided into 3 groups: mild, moderate, and severe dilation (Group A: LVEDD <6.0 cm [n = 22]; Group B: 6.0-7.0 cm [n = 32]; Group C: >7.0 cm [n = 48], respectively). Overall, recovery (successful explant without transplantation) occurred in 14 of 102 subjects (14%). Of these, 2 died and 2 required transplantation within 1 year. Recovery was more common in patients without LV dilation (Groups A/B/C = 32%/22%/0%, P < .001), as was sustained recovery (alive and transplant free 1 year after explant; A/B/C = 27%/10%/0%, P = .001). Of the recovery patients in Group A, 6/7 (86%) had sustained recovery versus 3/6 (50%) in Group B. Conclusions: Recovery occurred in 32% of NICM patients without significant LV dilation at time of VAD, the majority of whom experienced significant sustained recovery. Recovery was not evident in those with severe LV dilation. Routine echocardiography at the time of implant may assist in targeting patients for recovery after VAD. [Copyright &y& Elsevier]

Background: Although ventricular assist devices (VADs) provide effective treatment for end-stage heart failure, VAD support remains associated with significant risk for adverse events (AEs). To date there has been no detailed assessment of the incidence of a full range of AEs using standardized event definitions. We sought to characterize the frequency and timing of AE onset during the first 60 days of VAD support, a period during which clinical observation suggests the risk of incident AEs is high. Methods: A retrospective analysis was performed utilizing prospectively collected data from a single-site clinical database including 195 patients aged 18 or greater receiving VADs between 1996 and 2006. Adverse events were coded using standardized criteria. Cumulative incidence rates were determined, controlling for competing risks (death, transplantation, recovery-wean). Results: During the first 60 days after implantation, the most common AEs were bleeding, infection, and arrhythmias (cumulative incidence rates, 36% to 48%), followed by tamponade, respiratory events, reoperations, and neurologic events (24% to 31%). Other events (eg, hemolysis, renal, hepatic events) were less common (rates <15%). Some events (eg, bleeding, arrhythmias) showed steep onset rates early after implantation. Others (eg, infections, neurologic events) had gradual onsets during the 60-day period. Incidence of most events did not vary by implant era (1996 to 2000 vs 2001 to 2006) or by left ventricular versus biventricular support. Conclusions: Understanding differential temporal patterns of AE onset will allow preventive strategies to be targeted to the time periods when specific AE risks are greatest. The AE incidence rates provide benchmarks against which future studies of VAD-related risks may be compared. [Copyright &y& Elsevier]

Approximately 50% of heart failure (HF) cases diagnosed in the US is HF with preserved ejection fraction (HFpEF). The incidence of HFpEF increases annually and is associated with significant morbidity and mortality. Despite the increasing mortality, treatment options are limited. Beta-blockers (BB) have a significant mortality benefit in HF with reduced ejection fraction (HFrEF) but little is known regarding benefit in HFpEF. In this study we retrospectively analyzed the effect of BB on all-cause mortality in patients with HFpEF. This is a retrospective cohort study performed at a single academic center including patients admitted for a HF diagnosis between January 2011 and March 2020. Demographic information, clinical characteristics, and Charlson Deyo comorbidity scores were extracted from the EMR. Baseline differences were tested using Anova tests for continuous variables and chi-squared tests for categorical variables. Survival is reported using Kaplan-Meier curves at 30 days and 1 year; Cox proportional-hazards models are used to compute hazard ratios for BB versus non-BB groups for each endpoint. All statistical analyses were performed using SAS version 9.4. Table 1 shows all-cause mortality for BB and non-BB groups in patients with EF 40-55% and > 55% at 30 days and 12 months. BB group had no significant 30-day all-cause mortality benefit in patients with EF > 55%. When adjusted by Charlson Deyo comorbidity index, there was significant mortality benefit. In patients with EF > 55% on BB, there was significant mortality benefit at 12 months [Figure 1]. In patients with EF 40-55%, there was significant mortality benefit at 30 days and 12 months [Figure 2]. For patients with an EF of 40 - 55% and > 55%, Beta-blocker use showed significant mortality benefit. [ABSTRACT FROM AUTHOR]

Abstract: Background: Standard echocardiographic assessment of right ventricular (RV) function is problematic due to the complex RV geometry. We used tissue Doppler imaging to identify RV dysfunction in patients with pulmonary hypertension (PH). Methods: Study population consisted of 44 patients (mean age 52±11; 30 females) with PH who underwent color tissue Doppler imaging of the RV and right heart catheterization within 2 days of each other. Peak systolic velocity and strain were measured at the RV free wall and correlated with invasive measures of PH and RV function. Myocardial velocity and strain was also measured in 20 healthy volunteers who served as normal controls (mean age 47±13; 13 females). Results: PH patients had significantly reduced RV free wall velocity (6.4±2.1 cm/s vs. 8.2±2.1 cm/s; p <0.05) and RV strain (−18±7% vs. −28±6%; p <0.001) versus controls. RV peak strain demonstrated excellent correlation with transpulmonary gradient (r =0.72; p <0.001), pulmonary vascular resistance (r =0.73; p <0.001), and significant inverse correlation with cardiac index (r =−0.69; p <0.001). RV velocity had a significant, but weaker, correlation with cardiac index (r =0.33; p <0.05) and no association with transpulmonary gradient or pulmonary vascular resistance. In a multivariate model, RV strain but not RV velocity was independently associated with cardiac index. Conclusions: RV myocardial strain demonstrated excellent correlation with hemodynamic variables indicative of RV performance in PH patients. [Copyright &y& Elsevier]

Pulmonary hypertension (PH) is characterized by endothelial cell dysfunction and dysregulation of endogenous nitric oxide (NO) synthesis. NO bioavailability is further decreased due to dysregulation of the oral microbiome and reduction of dietary nitrate (NO3 -) to nitrite (NO2 -). PH biomarkers such as NT-proBNP have been associated with disease severity, prognosis and response to therapy. Emerging biomarkers like Endothelin-1 (ET-1) reflect NO signaling and cellular dysregulation. We evaluated the effect of a single dose of nitrate on NT-proBNP, ET-1, NO3 - and NO2 - levels in PH patients versus controls. Patients with prior right heart catheterization were administered 1000mg of sodium nitrate orally. Plasma NT-proBNP, ET-1, NO3 - and NO2 - were measured at baseline, 2, 6, and 24 hours following nitrate drug administration. Response of patients with PH (mPAP ≥ 25mmHg, TPG ≥ 12mmHg) was compared to controls (mean PAP < 25 mm Hg, PCWP ≤ 15 mm Hg). Nine patients were evaluated (control: n=4, age 53 ± 14 years, 100% female, EF 55 ± 0%, mPAP 19 ± 4 mmHg, PCWP 11 ± 3 mmHg, TPG 9 ± 4 mmHg, PVR 1.5 ± 0.6 WU; PH: n=5, age of 59 ± 9 years, 80% female, EF 58 ± 8%, mPAP 41 ± 8 mmHg, PCWP 26 ± 7 mmHg, TPG 14 ± 3 mmHg, PVR 2.9 ± 0.7 WU). Following oral nitrate dose, mean plasma NO3 - and NO2 - levels increased in both groups. NO3 - levels were significantly greater in the control vs PH group at 2 hrs (803 ± 404 µm vs 571 ± 202 µm) and 6 hrs (634 ± 254 µm vs 482 ± 183 µm) (overall P < 0.05). NO2 - levels were not significantly different (overall P = 0.17). ET-1 levels were significantly elevated in PH patients versus controls at baseline (3.0 ± 1.5 pg/mL vs 1.9 ± 0.3 pg/mL) and across all time points (overall P< 0.001). ET-1 showed a significant decline over time following oral nitrate dose in both PH (3.0 ± 1.5 pg/mL at 0 hrs to 2.8 ± 1.0 pg/mL at 24 hrs) and control (1.9 ± 0.3 pg/mL at 0 hrs to 1.6 ± 0.4 pg/mL at 24 hrs) (p<0.001; Figure 1). In contrast, NT-proBNP levels were similar in PH vs control; 810 ± 579 pg/mL vs 678 ± 836 pg/mL at baseline and 718.0 ± 415.6 pg/mL vs 290 ± 164.0 pg/mL at 24hrs (p=0.08). There was no significant change in NT-proBNP levels over time (p=0.60; Figure 2). ET-1 was significantly elevated in PH patients compared to controls and showed a significant decline over time after 1 dose of oral nitrate with associated increases in serum NO3 - and NO2 - levels. These changes were not observed with NT-proBNP. ET-1 may be an effective biomarker in monitoring changes in NO metabolism in PH, and may be more acutely responsive than NT-proBNP. [ABSTRACT FROM AUTHOR]

Abstract: Background: The development of right ventricular dysfunction is a poor prognostic sign in patients with heart failure (HF). Although left ventricular dyssynchrony has been well described, it is not known whether right ventricular dyssynchrony coexists in HF. We used tissue Doppler imaging to determine whether right ventricular dyssynchrony is also present in HF patients. Methods and Results: In 34 HF patients (mean age 56 ± 13 years), we measured longitudinal strain at the right ventricular free wall, interventricular septum, and left ventricular lateral wall. Right ventricular and left ventricular dyssynchrony were defined as the difference in time to peak strain between the right ventricular free wall and the septum and between the left ventricular lateral wall and septum, respectively. Mean right ventricular dyssynchrony was 59 ± 45 ms and the mean left ventricular dyssynchrony was 80 ± 62 ms. We found a strong correlation between right ventricular dyssynchrony and pulmonary artery systolic pressure (r = 0.73; P < .001) and a negative correlation between right ventricular dyssynchrony and right ventricular fractional area change (r = −0.43; P < .02). Conclusion: HF patients exhibit right ventricular dyssynchrony by strain imaging which correlates with pulmonary hypertension and right ventricular dysfunction. [Copyright &y& Elsevier]

Background: Ventricular assist devices (VADs) are approved for destination therapy because they improve survival in end-stage heart failure (HF). VADs are powered pneumatically or electrically. Pneumatic and electric left ventricular assist devices (LVADs) and biventricular assist devices (BiVADs) provide excellent hemodynamic support at rest, but differences in their effects on exercise tolerance are unclear. We sought to evaluate the effect of devices with varying operating parameters on exercise capacity. Methods: Exercise physiology data obtained during maximal exercise with on-line gas-exchange analysis were collected for 38 consecutive VAD-implanted HF patients referred for exercise testing. Results: Electric LVADs were implanted in 18 patients, and pneumatic LVADs in 10 patients. Percent of predicted peak exercise oxygen consumption (Vo 2%) was significantly greater in pneumatic LVAD patients (52.1 ± 11.1% vs 38.2 ± 11.3%, p < 0.05). The 10 patients implanted with a pneumatically powered LVAD were compared to 10 patients implanted with a pneumatically powered BiVAD. LVAD-supported patients had a higher Vo 2% (52.1 ± 11.1% vs 36.5 ± 17.7%, p < 0.05). Conclusions: HF patients supported with a pneumatic LVAD appear to have better exercise tolerance than those receiving an electric LVAD. Patients on LVAD support have better exercise tolerance than BiVAD-supported patients. This highlights the importance of right ventricular function to exercise tolerance in HF patients, and may have implications for future VAD design. [Copyright &y& Elsevier]