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Background: Patients who are diagnosed with heart failure (HF) are almost universally characterized by left ventricular ejection fraction (LVEF) at the time of diagnosis, where the most common dichotomy is preserved LVEF (HFpEF, LVEF > 50%) or reduced LVEF (HFrEF, LVEF < 40%). The concept of recovered LVEF (< 40% to > =50%) is considered by some to indicate a separate category of HF. We sought to study the natural history of a patient’s LVEF using natural language processing among a large cohort of patients. Methods: We identified 457,457 patients in the VA Health Care System between 2005 and 2016 with a first outpatient diagnosis of heart failure with an LVEF between 6 months before or one year after the heart failure diagnosis and a second LVEF after the diagnosis. We used all LVEF data from 2005-2016 obtained from previously validated natural language processing of echo reports. LVEF at baseline was grouped into deciles (1-29, 30-39, 40-49, 50-59, 60-69 and >=70%). Results: The 457,457 patients had 8,857,436 echos over a mean 4 +/- 3 years of follow-up (median 11 echos per patient). At the time of diagnosis the mean age was 69 +/- 11 years, 97.6% male, 19% were African-American, 45% had a diagnosis of diabetes, and 61% had a diagnosis of ischemic heart disease. During follow-up among those with an initial LVEF < 40%, between 21% and 31% recovered their LVEF to over 50% at some point during follow-up (Table). A similar frequency was noted for those dropping to an LVEF < 40% if the initial LVEF was high. When the last LVEF was used to define change, then a recovered LVEF (>50%) was less common (9% if initial LVEF was < 20%, 8% if the initial LVEF was 20-29%, 13% if the initial LVEF was 30-39%). The final LVEF was < 40% in 30% of patients with an initial LVEF of 40-49%, 15% if the initial LVEF was 50-59%, 9% if the initial LVEF was 60-69%, and 6% if the initial LVEF was >=70%. Conclusion: In this multiyear study of a national cohort, LVEF varied substantially over time, with a recovered LVEF (=50%) noted at some point in 20-30% depending on initial LVEF. However, when the last LVEF is used, recovery occurred in only 8-13%. Thus, approximately half of patients with a recovered LVEF at some point will revert to depressed LVEF.

Background: Numerous quality metrics for heart failure care now exist based on process (from clinical guidelines) or outcome (readmission and mortality). It is unclear, however, how valid these measures are at serving as indicators of hospital quality for patients with heart failure (HF). We sought to determine validity by comparing convergent validity (correlation among measures) and reliability (correlation over time). Methods: We gathered data on several HF performance measures from the Veterans Affairs Health Care System from 2008-2013. Process data are collected through chart review of a random sample of facilities. There are between 114 and 119 facilities that have at least one patient that is a treatment candidate each year. There are a mean 72 patients per facility per year included. For each facility and each year, we determined, among ideal candidates, use of ACE-inhibitor (ACEi), any beta-blocker (BB), recommended beta-blocker (rBB) (carvedilol, metoprolol succinate, bisoprolol), mineralocorticoid receptor antagonist (MRA), hydralazine/isosorbide dinitrate in African Americans, as well as rates of 30-day readmission, 30-day mortality, and 1-year mortality. We measured validity in 2 ways: determining correlations between measures, assuming that if a measure is associated with overall “quality” that it should be correlated with the other measures, and year-to-year reliability, assuming that if a measure has a good signal/noise ratio then there should be a strong correlation from one year to the next. Results: Data were available for 55,735 hospitalizations for HF from 2008-2013. In determining correlations between performance measures, we found a statistically significant correlation between ACEi and rBB (R=0.25, p Conclusion: BB, ACEi and MRA use rates showed evidence of validity as measures of HF quality through correlation with each other, mortality and/or year to year reliability. In contrast, 30-day readmission was poorly correlated with process of care and mortality and had poor reliability.

METHODS: 103 patients with degenerative mitral regurgitation (MR) underwent single-suture repair of the mitral valve through a 3-cm right chest incision from May 2007 through December 2012. The prolapsed segment of the mitral valve was imbricated with a double running CV 5 Gore-Tex suture, resulting in a smooth plane of coaptation. Preoperative and perioperative echocardiograms as well as patient outcomes were analyzed and compared to patients undergoing minimally invasive isolated mitral valve repair using quadrangular resection at the same institution during the same time period.