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Introduction: Accurate assessment of the risk of adverse outcomes can assist in the management of patients with heart failure (HF). Hypothesis: Health-related quality of life (HRQoL) can improve prediction of HF outcomes beyond that of the more traditional clinical disease characteristics. Methods: We included consecutive patients with HF with reduced ejection fraction (HFrEF) who were seen in the HF clinic and completed patient reported outcome assessment (PROs) as part of routine care. Elastic net and gradient boosting regression analysis were used to build predictive models for HF hospitalization, heart transplant, left ventricular assist device implantation or death (composite outcome), including a range of clinical variables and PRO results as covariates. Results: There were 1,165 patients with HFrEF (mean age 60.5±16.2, 65% male) with median follow-up time of 490 days. Addition of PROs to more traditional risk factors improved model performance, as analyzed by C-statistics. The gradient boosting regression was chosen as the final model based on superior prediction performance - c-statistic 0.733 and favorable stratification of patient risk - Figure 1A . The Kansas City Cardiomyopathy Questionnaire overall summary score (KCCQ) and PROMIS dimensions of Satisfaction with social roles and activities and Physical function were covariates with high variable importance measure in the model. The predictive value of PROs was also confirmed by determining freedom from the composite endpoint in the 20th, 50th and 80th percentiles of PRO strata, while assigning the remaining clinical variables a median value ( Figure 1B ). In this analysis, PROs discriminated outcomes independent of other clinical characteristics. Conclusions: HRQoL appears to significantly modify outcome in HFrEF. Routine assessment of PROs could help to more accurately assess risk of adverse outcomes and personalize informed treatment decisions.

Background: Variable definitions and an incomplete understanding of the gradient of reverse cardiac remodeling following continuous flow left ventricular assist device (LVAD) implantation has limited the field of myocardial plasticity. We evaluated the continuum of LV remodeling by serial echocardiographic imaging to define 3 stages of reverse cardiac remodeling following LVAD. Methods: The study enrolled consecutive LVAD patients across 4 study sites. A blinded echocardiographer evaluated the degree of structural (LV internal dimension at end-diastole [LVIDd]) and functional (LV ejection fraction [LVEF]) change after LVAD. Patients experiencing an improvement in LVEF ≥40% and LVIDd ≤6.0 cm were termed responders, absolute change in LVEF of ≥5% and LVEF Results: Among 358 LVAD patients, 34 (10%) were responders, 112 (31%) partial responders, and the remaining 212 (59%) were nonresponders. The use of guideline-directed medical therapy for heart failure was higher in partial responders and responders. Structural changes (LVIDd) followed a different pattern with significant improvements even in patients who had minimal LVEF improvement. With mechanical unloading, the median reduction in LVIDd was −0.6 cm (interquartile range [IQR], −1.1 to −0.1 cm; nonresponders), −1.1 cm (IQR, −1.8 to −0.4 cm; partial responders), and −1.9 cm (IQR, −2.9 to −1.1 cm; responders). Similarly, the median change in LVEF was −2% (IQR, −6% to 1%), 9% (IQR, 6%–14%), and 27% (IQR, 23%–33%), respectively. Conclusions: Reverse cardiac remodeling associated with durable LVAD support is not an all-or-none phenomenon and manifests in a continuous spectrum. Defining 3 stages across this continuum can inform clinical management, facilitate the field of myocardial plasticity, and improve the design of future investigations.

Introduction: Left ventricular assist device (LVAD) therapy aims to improve LV reverse remodeling, but still >50% of chronic heart failure (CHF) patients show ‘no’ recovery. The current clinical paradigm to assess post-LVAD myocardial recovery relies on ventricular rotational and deformational mechanics. Investigating the role of a pre-LVAD QRS as a potential indicator for post-LVAD LV recovery in CHF patients may help clinicians develop optimal care plans for LVAD patients. Hypothesis: Pre-LVAD short QRS has potential value to be useful as an independent predictor for early myocardial recovery following LVAD implantation. Methods: Chronic and dilated cardiomyopathy patients (n=315) undergoing LVAD implantation were retrospectively studied. Acute HF etiology and post-LVAD follow up (6 cm. From 315 LVAD patients, 39 fulfilled the criteria of myocardial recovery as ‘R’. Results: Based on univariate logistic regression, pre-LVAD QRS duration is found to be a predictor of myocardial recovery following LVAD implantation (OR:0.986, 95% CI:0.976-0.996, p=0.005) in LVAD patients. QRS duration is 14.5% longer in the ‘NR’ group as compared with the ‘R’ group (145±36 ms vs 124±37 ms). In multivariate logistic regression, after adjusting for previous thoracotomy, beta-blockers, and a previously evaluated composite score (UCARS) including age, HF duration, and LVEDD, pre-LVAD QRS remains a significant predictor of ‘R’ status (OR:0.983, 95% CL:0.973-0.994, p=0.003). The model shows an accuracy of 0.74 with a p-value of Conclusions: Pre-LVAD short QRS interval is associated with post-LVAD LV reverse remodeling in the ‘R’ group, and thus could be of use in a clinical setting for predicting post-LVAD early myocardial recovery.

Background: Gastrointestinal bleeding (GIB) is a leading cause of morbidity during continuous-flow left ventricular assist device (CF-LVAD) support. GIB risk assessment could have important implications for candidate selection, informed consent, and postimplant therapeutic strategies. The aim of the study is to derive and validate a predictive model of GIB in CF-LVAD patients. Methods and Results: CF-LVAD recipients at the Utah Transplantation Affiliated Hospitals program between 2004 and 2017 were included. GIB associated with a decrease in hemoglobin ≥2 g/dL was the primary end point. A weighted score comprising preimplant variables independently associated with GIB was derived and internally validated. A total of 351 patients (median age, 59 years; 82% male) were included. After a median of 196 days, GIB occurred in 120 (34%) patients. Independent predictors of GIB included age >54 years, history of previous bleeding, coronary artery disease, chronic kidney disease, severe right ventricular dysfunction, mean pulmonary artery pressure 107 mg/dL. A weighted score termed Utah bleeding risk score, effectively stratified patients based on their probability of GIB: low (0–1 points) 4.8%, intermediate (2–4) 39.8%, and high risk (5–9) 83.8%. Discrimination was good in the development sample (c-index: 0.83) and after internal bootstrap validation (c-index: 0.74). Conclusions: The novel Utah bleeding risk score is a simple tool that can provide personalized GIB risk estimates in CF-LVAD patients. This scoring system may assist clinicians and investigators in designing tailored risk-based strategies aimed at reducing the burden posed by GIB in the individual CF-LVAD patient and healthcare systems.

Background: Cardiac allograft vasculopathy (CAV) remains an important source of mortality after heart transplant. The aim of our study was to identify structural and microvasculature changes in severe CAV. Methods and Results: The study group included heart transplant recipients with severe CAV who underwent retransplantation (severe CAV, n=20). Control groups included time from transplant matched cardiac transplant recipients without CAV (transplant control, n=20), severe ischemic cardiomyopathy patients requiring left ventricular assist device implantation (ischemic control, n=18), and normal hearts donated for research (donor control, n=10). We collected baseline demographic information, echocardiography data, and performed histopathologic examination of myocardial microvasculature. Echocardiographic features of severe CAV included lack of eccentric remodeling and presence of significant diastolic dysfunction. In contrast, diastolic function was preserved in transplant control subjects. Histopathologic examination showed increased interstitial fibrosis among severe CAV, transplant controls, and ischemic control patients. Compared with transplant controls, severe CAV subjects had reduced capillary density and increased capillary wall thickness ( P Conclusions: Our results suggest that the marked diastolic dysfunction and resultant symptoms in patients with severe CAV may be secondary to the loss of microvasculature and remodeling of remaining microvessels rather than a consequence of interstitial fibrosis. The clinical significance and potential therapeutic implications of these unique microvasculature characteristics warrant further investigation.

See Article by Parker et al The national heart allograft allocation algorithm established by the Organ Procurement and Transplantation Network has undergone several major changes over the years. The main goals of these policy modifications have been to respond to the evolving treatment options for advanced heart failure patients, minimize the risk of death on the waiting list, and maximize the benefit of transplant.1 An aspirational goal has also been to achieve as much uniformity as possible in the practical application of the allocation algorithm. Every modification of the allocation policy in the past has been met with a good dose of anxiety in anticipation of what the implemented change will mean. Will the benefits to transplant candidates predicted by the statistical modeling of waiting list events be realized? Will the change affect the required level of staffing or the established process logistics of organizations participating in donation, procurement, and transplantation? Will the change alter transplant volumes at one’s transplant center? Yet, the more contentious aspect has typically been the issue of uniform application of the policy from one transplant program to another and from patient to patient—a subject matter that can be best characterized as fairness. In this issue of Circulation: Heart Failure , Parker et al2 present their evaluation of one aspect of the fairness of the current heart allocation in the United States. They hypothesized that changes have taken place over time in the listing practices under the current Organ Procurement and Transplantation Network allocation …

Background— Patients with human immunodeficiency virus (HIV) infection are at increased risk of accelerated coronary artery disease (CAD) and cardiovascular events. Stress echocardiography (SE) is routinely used for risk stratification and prognosis of patients with known or suspected CAD. The prognostic value of SE in this high-risk group is unknown. The purpose of this study was to evaluate the prognostic value of SE in HIV-infected patients with known or suspected CAD. Methods and Results— We evaluated 311 patients (age, 52±9 years; 74% men; left ventricular ejection fraction, 54±12%) with history of HIV, undergoing SE (56% dobutamine). Left ventricular wall motion was evaluated on a 16-segment model, 5-point scale. An abnormal SE was defined by a fixed (infarction), biphasic, or new (ischemia) wall motion abnormality on stress. Follow-up for cardiac death and myocardial infarction was obtained. Seventy-nine (26%) patients had an abnormal SE. After 2.9±1.9 years, 17 confirmed myocardial infarction and 14 cardiac deaths occurred. SE risk-stratified patients into normal versus abnormal subgroups (event rate, 0.6% per year versus 11.8% per year; P P P =0.009) were independent predictors of cardiac events. On a forward conditional Cox proportional hazards regression model, SE provided incremental prognostic value over clinical, stress ECG, and resting echocardiographic variables (global χ 2 increased from 17.8 to 24.5 to 65 to 109, P Conclusions— SE can effectively risk-stratify and prognosticate patients with HIV. The presence of ischemia and scar during SE provides independent and incremental prognostic value over traditional variables. A normal SE response portends a benign prognosis even in this high-risk subset.

Japanese-variant or apical hypertrophic cardiomyopathy (HCM) is a specific type of HCM, first described in Japan and initially thought to carry a benign prognosis. However, current evidence suggests that these patients experience severe symptoms and are at increased risk of ventricular arrhythmias and death, especially in the presence of an apical akinetic chamber. The management of patients who do not respond to medical therapy is challenging. We describe a patient with Japanese-variant HCM, with an apical akinetic chamber and severe symptoms who failed medical therapy. The use of dual chamber pacing relieved obstruction and significantly improved the patient’s symptoms.

PURPOSE To compare the utilization of evidence-based (EB) cardiac therapies and clinical outcomes of cardiac care on general medicine inpatient services under teaching and nonteaching services at an academic hospital. METHODS In 2005 we implemented the Advanced Cardiac Admission Protocol (ACAP) for all cardiac patients admitted to our hospital. 4170 patients were admitted with ACS or HF were assigned to a resident-staffed teaching service ( n = 3890) or to a hospitalist-nonteaching service ( n = 280). We compared utilization of EB therapies, hospital readmission rate at 30 days, length of hospital stay (LOS), and all-cause mortality at 90 days. RESULTS The cohort mean age was 63 ± 15 years, 55% males. 34% had diabetes, 74% were hypertensive and 41% had hyperlipidemia. Mean LVEF was 50 ± 22% and mean TIMI risk score was 2.7 ± 1.5. There were no difference between both services in regards to the utilization of all EB therapies, BB (62 vs. 63%), ACEi (56 vs. 57%), ASA (83 vs. 80%), anticoagulation (58 vs. 63) and Statins (68 vs. 67%). Clinical outcomes including LOS (4.95 days vs. 5.14 days; P = .24), readmission rate (10.5% vs. 11%; P = .21), and all-cause mortality (4.0% vs. 3.4%; P = .64) were similar. CONCLUSIONS At our academic hospital, implementation of a standardized novel pathway for cardiac patients led to comparable outcomes between teaching and nonteaching services.