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Background & Aims The risk of gastrointestinal (GI) bleeding (GIB) and thromboembolic events may increase with continuous-flow left ventricular assist devices (CF-LVADs). We aimed to characterize GIB and thromboembolic events that occurred in patients with CF-LVADs and compare them with patients receiving anticoagulation therapy. Methods We performed a retrospective analysis of 159 patients who underwent CF-LVAD placement at 2 large academic medical centers (mean age, 55 ± 13 y). We identified and characterized episodes of GIB and thromboembolic events through chart review; data were collected from a time period of 292 ± 281 days. We compared the rates of GIB and thromboembolic events between patients who underwent CF-LVAD placement and a control group of 159 patients (mean age, 64 ± 15 y) who received a cardiac valve replacement and were discharged with anticoagulation therapy. Results Bleeding events occurred in 29 patients on CF-LVAD support (18%; 45 events total). Sixteen rebleeding events were identified among 10 patients (range, 1-3 rebleeding episodes/patient). There were 34 thrombotic events among 27 patients (17%). The most common source of bleeding was GI angiodysplastic lesions (n = 20; 44%). GIB and thromboembolic events were more common in patients on CF-LVAD support than controls; these included initial GIB (18% vs 4%, P < .001), rebleeding (6% vs none, P = .001), and thromboembolic events (17% vs 8%, P = .01). Conclusions Patients with CF-LVADS receiving anticoagulants have a significantly higher risk of GIB and thromboembolic events than patients receiving anticoagulants after cardiac valve replacement surgery. GI angiodysplastic lesions are the most common source of bleeding. [ABSTRACT FROM AUTHOR]

Heart failure (HF) remains a major cause of morbidity and mortality worldwide. Major advancements in optimal guideline-directed medical therapy, including novel pharmacological agents, are now available for the treatment of chronic HF including HF with reduced ejection fraction and HF with preserved ejection fraction. Despite these efforts, there are several limitations of medical therapy including but not limited to: delays in implementation and/or initiation; inability to achieve target dosing; tolerability; adherence; and recurrent and chronic costs of care. A significant proportion of patients remain symptomatic with poor HF-related outcomes including rehospitalization, progression of disease, and mortality. Driven by these unmet clinical needs, there has been a significant growth of innovative device-based interventions across all HF phenotypes over the past several decades. This state-of-the-art review will summarize the current landscape of guideline-directed medical therapy for chronic HF, discuss its limitations including barriers to implementation, and review device-based therapies which have established efficacy or demonstrated promise in the management of chronic HF., (© 2023 The Author(s).)

An ensemble of J HH , J CH , and J CC values was measured in aqueous solutions of methyl α- and β-d-idohexopyranosides containing selective 13 C-enrichment at various carbons. By comparing these J-couplings to those reported previously in the α- and β-d-idohexopyranoses, methyl glycosidation was found to affect ring conformational equilibria, with the percentages of 4 C 1 forms based on 3 J HH analysis as follows: α-d-idopyranose, ∼18%; methyl α-d-idopyranoside, ∼42%; methyl β-d-idopyranoside, ∼74%; β-d-idopyranose, 82%. J CH and J CC values were analyzed with assistance from theoretical values obtained from density functional theory (DFT) calculations. Linearized plots of the percentages of 4 C 1 against limiting J CH and J CC values in the chair forms were used to (a) determine the compatibility of the experimental J CH and J CC values with 4 C 1 / 1 C 4 ratios determined from J HH analysis and (b) determine the sensitivity of specific J CH and J CC values to ring conformation. Ring conformational equilibria for methyl idohexopyranosides differ significantly from those predicted from recent molecular dynamics (MD) simulations, indicating that equilibria determined by MD for ring configurations with energetically flat pseudorotational itineraries may not be quantitative. J-couplings in methyl α-l-[6- 13 C]idopyranosiduronic acid and methyl α-d-[6- 13 C]glucopyranosiduronic acid were measured as a function of solution pH. The ring conformational equilibrium is pH-dependent in the iduronic acid.

Background: Diastolic pulmonary gradient (DPG), calculated as the difference between pulmonary artery diastolic pressure and mean pulmonary capillary wedge pressure ≥ 7 mmHg is associated with pulmonary vascular disease and portends poor prognosis in heart failure (HF). The prognostic relevance of DPG in group 1 pulmonary hypertension (PH) is uncertain., Methods: Using the Pulmonary Hypertension Connection (PHC) risk equation for 225 patients in the NIH-PPH, the 5-year probability of death was calculated, which was then compared with DPG using a Cox proportional hazards model. Kaplan-Meier survival curves were determined for two cohorts using the median DPG of 30 mmHg as cutoff, and significance was tested using the log-rank test., Results: The mean age was 38.1 ± 16.0 years old, 63% female, and 72% were "white". The mean DPG was 31.6 mmHg ± 13.8 mm Hg and only 1.8% had a DPG <7 mm Hg. Increasing DPG was significantly associated with increased 5-year mortality even after adjustment for the PHC risk equation (HR 1.29 per 10 mm Hg increase). When DPG was dichotomized based on the median of 30 mm Hg, the HR for DPG >30 mm Hg with respect to 5-year mortality was 2.03. After adjustment for pulmonary artery systolic pressure (PASP), increasing DPG remained significantly associated with decreased 5 years survival (HR 1.99 for DPG > 30 mm Hg)., Conclusions: DPG is independently associated with survival in group 1 PH patients even after adjustment for the PHC risk equation or PASP. Patients with increased DPG had a 2-fold increased risk of mortality. The use of DPG for guiding treatment and prognosis in group 1 PH should be further investigated., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Over the past 15 years, the field of mechanical circulatory support has developed significantly. Currently, there are a multitude of options for both short and long term cardiac support. Choosing the appropriate device for each patient depends on the amount of support needed and the goals of care. This article focuses on long term, implantable devices for both bridge to transplantation and destination therapy indications. Implantation strategies, including the appropriate concomitant surgeries are discussed as well as expected long term outcomes. As device technology continues to improve, long term mechanical circulatory support may become a viable alternative to transplantation.

Left ventricular assist devices (LVADs) are increasingly utilized in the management of advanced heart failure. A transcutaneous driveline is necessary to power the LVAD, and although this technology has improved over the years in terms of smaller size and increased durability, driveline complications continue to develop in up to 20% of all devices implanted. Driveline infections are associated with significant morbidity and mortality. As more patients live longer with ventricular assist devices, minimizing driveline infections is paramount. A systematic, multidisciplinary approach can be used to develop a strategy to prevent, recognize and treat driveline infections. In this paper, we describe our approach to driveline management which has resulted in zero driveline infections between January 2012 and March 2014.

Objective: This study assessed the impact of pulmonary hypertension (PH) on morbidity and mortality after the most common cardiac operations and evaluated the accuracy of the Society of Thoracic Surgeons (STS) risk model for patients with PH., Methods: At a single center between 1994 and 2010, all adult cardiac operations performed with recorded preoperative mean pulmonary arterial pressure (MPAP) and STS predicted mortality were reviewed. MPAP was defined as normal (<25 mm Hg) or as mild (25-34 mm Hg), moderate (35-44 mm Hg), or severe (≥ 45 mm Hg) PH. Multivariate analysis was performed to elucidate the contribution of PH to morbidity and mortality., Results: In all, 3343 patient records were reviewed. Coronary artery bypass grafting (CABG) was the most common procedure (67.5%), followed by aortic valve replacement (24.9%) and mitral valve procedures (6.3%). Postoperative complications and mortality increased with increasing MPAP. Multivariable analysis found that both moderate (odds ratio, 7.17; P < .001) and severe (odds ratio, 13.73; P < .001) PH were significantly associated with increased mortality, even after accounting for STS risk. A subset analysis of isolated CABG cases revealed markedly increased mortality for all categories of PH (mild odds ratio, 1.99; moderate odds ratio, 11.5; severe odds ratio, 38.9; P < .001)., Conclusions: Morbidity and mortality were independently associated with PH. Observed mortality was significantly higher than predicted by the STS model for patients with moderate and severe PH, particularly in isolated CABG. Addition of PH to the STS risk model should be considered, or alternative tools should be used to assess risk in these patients., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Paravalvular leaks following valve replacement can result in heart failure and hemolysis. Surgical intervention is the treatment of choice, but it carries substantial risk of morbidity and mortality. Percutaneous techniques using devices designed for congenital heart disease are increasingly applied to the treatment of paravalvular leaks. We present the case of a mitral paravalvular leak treated with an Amplatzer occluder device. Unfortunately, the device occluded flow through the mitral valve, resulting in symptomatic mitral stenosis requiring surgical intervention., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)