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Background: Studies have indicated differences between Asians and Whites in their propensity for stroke, coronary artery disease, heart failure, bleeding and thrombosis. We investigated whether Asian-Americans on durable left ventricular assist devices (LVADs) exhibit differential morbidity and mortality when compared to Whites.Methods: We analysed prospectively collected data from the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database to compare the outcomes after LVAD implantation of Asians versus Whites.Results: In total, 7,018 patients were included, 130 were identified as Asian-Americans. Asian-Americans were younger, had lower body mass index, higher serum bilirubin and lower albumin levels. In a multivariable regression model, there was no difference in survival between the two groups. Asian-Americans had lower incidence of device malfunction and after adjusting for multiple factors this remained lower. The adjusted risk of a major safety composite outcome, including major bleeding, major infection, stroke and device malfunction, revealed no difference between the two groups.Conclusions: Although prior studies have reported worse cardiac surgery outcomes in Asians, in this INTERMACS analysis Asian-Americans appear to have similar survival and risk of adverse events as their White counterparts. The incidence of device malfunction was lower in the Asian-Americans, both in a univariate model and after adjusting for multiple clinical factors. Future, larger studies of Asian-Americans with end-stage heart failure and LVAD support are warranted to confirm these results. [ABSTRACT FROM AUTHOR]

Aims: Adjuvant heart failure (HF) drug therapy in patients undergoing chronic mechanical circulatory support (MCS) is often used in conjunction with a continuous-flow left ventricular assist device (LVAD), but its potential impact is not well defined. The objective of the present study was to examine the effects of conventional HF drug therapy on myocardial structure and function, peripheral organ function and the incidence of adverse events in the setting of MCS.Methods and Results: Patients with chronic HF requiring LVAD support were prospectively enrolled. Paired myocardial tissue samples were obtained prior to LVAD implantation and at transplantation for histopathology. The Meds group comprised patients treated with neurohormonal blocking therapy (concurrent beta-blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and aldosterone antagonist), and the No Meds group comprised patients on none of these. Both the Meds (n = 37) and No Meds (n = 44) groups experienced significant improvements in cardiac structure and function over the 6 months following LVAD implantation. The degree of improvement was greater in the Meds group, including after adjustment for baseline differences. There were no differences between the two groups in arrhythmias, end-organ injury, or neurological events. In patients with high baseline pre-LVAD myocardial fibrosis, treatment with HF drug therapy was associated with a reduction in fibrosis.Conclusions: Clinical and histopathological evidence showed that adjuvant HF drug therapy was associated with additional favourable effects on the structure and function of the unloaded myocardium that extended beyond the beneficial effects attributed to LVAD-induced unloading alone. Adjuvant HF drug therapy did not influence the incidence of major post-LVAD adverse events during the follow-up period. [ABSTRACT FROM AUTHOR]

BACKGROUND: Impaired qualitative and quantitative left ventricular (LV) rotational mechanics predict cardiac remodeling progression and prognosis after myocardial infarction. We investigated whether cardiac rotational mechanics can predict cardiac recovery in chronic advanced cardiomyopathy patients. METHODS AND RESULTS: Sixty-three patients with advanced and chronic dilated cardiomyopathy undergoing implantation of LV assist device (LVAD) were prospectively investigated using speckle tracking echocardiography. Acute heart failure patients were prospectively excluded. We evaluated LV rotational mechanics (apical and basal LV twist, LV torsion) and deformational mechanics (circumferential and longitudinal strain) before LVAD implantation. Cardiac recovery post-LVAD implantation was defined as (1) final resulting LV ejection fraction ≥40%, (2) relative LV ejection fraction increase ≥50%, (iii) relative LV end-systolic volume decrease ≥50% (all 3 required). Twelve patients fulfilled the criteria for cardiac recovery (Rec Group). The Rec Group had significantly less impaired pre-LVAD peak LV torsion compared with the Non-Rec Group. Notably, both groups had similarly reduced pre-LVAD LV ejection fraction. By receiver operating characteristic curve analysis, pre-LVAD peak LV torsion of 0.35 degrees/cm had a 92% sensitivity and a 73% specificity in predicting cardiac recovery. Peak LV torsion before LVAD implantation was found to be an independent predictor of cardiac recovery after LVAD implantation (odds ratio, 0.65 per 0.1 degrees/cm [0.49-0.87]; P=0.014). CONCLUSIONS: LV rotational mechanics seem to be useful in selecting patients prone to cardiac recovery after mechanical unloading induced by LVADs. Future studies should investigate the utility of these markers in predicting durable cardiac recovery after the explantation of the cardiac assist device. [ABSTRACT FROM AUTHOR]

Cardiac amyloidosis (CA) and coronary artery disease (CAD) can have similar presentations in the acute care setting. They both share signs, symptoms, and elevation of cardiac biomarkers (B-natriuretic peptide and troponin) potentially delaying the diagnosis of CA. The prevalence, and clinical characteristics of patients with concomitant CA and coronary artery disease (CAD) have not been described. CAD is prevalent among CA patients and leads to worse outcomes when compared to CA alone. We conducted a retrospective analysis of patients referred to our institution for evaluation of cardiac amyloidosis. We obtained demographic and clinical characteristics, laboratory data, and echocardiographic measurements of those patients with confirmed cardiac amyloidosis. The population was divided into two groups based on the presence of CAD. The frequency of heart failure hospitalizations and one-year mortality were compared between both groups. Between 2018 to 2021, 327 patients with suspected cardiac amyloidosis were referred to our institution. Out of 109 confirmed CA patients, 29 patients (26%) had concomitant CAD and CA. The overall mean age of CA diagnosis was 74.1 (±8.2) years for CAD group and 67 (±9.8) for the non-CAD group (P value <0.001). There were more males in the CAD group (93.1% vs. 60%, p-value <0.001), higher prevalence of hypertension (93.1% vs 70%, p-value 0.011) and dyslipidemia (89.7% vs 58.8%, p-value 0.002) were also found in the CAD group. Left atrial volume index (LAVI) was higher in the CAD group, 57mL/m2 vs 46 mL/m2 (p-value 0.002). Overall, there were no significant differences in outcomes (Table 1). Larger studies are needed to identify characteristics that will result in a prompt diagnosis of CA in patients with concomitant CAD, even though, our study showed no difference in outcomes, this was likely due to the small sample size. [ABSTRACT FROM AUTHOR]

Hyponatremia is common in heart failure and is a well-established indicator of adverse outcomes. The clinical implication of hyponatremia in left ventricular assist device (LVAD) patients remains understudied. We evaluated the association between pre-LVAD implant hyponatremia and one-year post LVAD outcomes. Retrospective study of LVAD (exclusively HM 3 devices) implants between 8/2015 to 7/2020 at our institution. We divided our population based on their serum sodium the morning prior to LVAD implantation; Group 1: hyponatremia if <135 mEq/L and Group2: normal sodium if ≥135 mEq/L. We compared one-year outcomes between groups. Primary endpoint was a composite outcome of HF admission and mortality. Secondary endpoints were HF admissions, mortality and heart transplantation. In a secondary analysis, we compared outcomes between different sodium groups pre and post LVAD. A total of 195 patients were included. Mean age at implant was 52.2, male accounted for 78.5%, non-ischemic cardiomyopathy 74.4%. Preimplant hyponatremia was present in 40% with mean sodium of 132.1 vs 137.8 in the normal sodium group. Preimplant hyponatremia revealed no significant differences in any of the primary or secondary endpoints (Table 1). Secondary analysis comparing sodium groups pre vs. post LVAD (at discharge) also showed no differences in outcomes at one year (Table 2). Neither pre-implant hyponatremia nor sodium groups at discharge were associated with adverse outcomes. This could be a result of adequate LV unloading and end organ perfusion which suggests other unclear mechanisms for ongoing hyponatremia. Regardless of the cause, these results suggest that optimization of mild hyponatremia may not be critical in LVAD patients and should not delay LVAD placement. [ABSTRACT FROM AUTHOR]

There is little evidence about the short-term outcomes of patients undergoing implantation of ventricular assist devices (VADs) who require initiation of chronic intermittent hemodialysis (IHD). Filling this knowledge gap may help anticipate potential complications and improve outcomes. This is a chart review, retrospective study that included all patients who underwent VAD implantation followed by initiation of IHD at our center. Intermittent hemodialysis was defined as ≤6-hour sessions, 3-4 times weekly. Continuous renal replacement therapy (CRRT) did not meet this inclusion criteria. Continuous and categorical variables were expressed in means (standard deviation) and numbers (%), respectively. Among the 11 patients that met inclusion criteria, 6 (54.6%) were female, 6 (54.6%) were African American, 6 (54.6%) had non-ischemic cardiomyopathy, 6 were being bridged to HT, and 9 (81.8%) had chronic kidney disease. Home regimen was available for 10 patients, all of whom were taking loop diuretics, but only 7 (70%) and 3 (30%) of them had medical regimens with ACEIs or ARBs, and spironolactone, respectively. All patients received tunneled catheters, and in 2 of them AV fistulas were performed afterwards. At least 3 patients experienced asymptomatic hypotension (<60 mm Hg) during the first 10 IHD sessions, leading to finishing the session early in one of the cases. Another patient had catheter thrombosis leading to catheter exchange. No other major event was documented during the 10 initial IHD sessions. One patient started IHD outpatient without complications. Among the 10 (90.9%) patients who started IHD during index hospitalization, the length of hospital stay was 81.5 (±40.7) days, and their most relevant complications were death (1), stroke (1), infections (5), gastrointestinal bleeding (4), right ventricular failure (2), and tracheostomy (1). For those who started IHD during index hospitalization, time to first readmission was 44.6 (±36.3) days, with 4 (44.4%) patients being readmitted within 30 days, and 1 of them dying during the first readmission. Additional information is found in Table 1. This study confirms feasibility of IHD initiation after VAD implantation, even as outpatient, but also proves a high burden of morbidity during index hospitalization and short-term follow up. Larger studies prospective studies with the newest VADs could provide valuable insight into this strategy for left ventricular and renal replacement therapies. [ABSTRACT FROM AUTHOR]

Severe renal dysfunction is a contraindication for receiving ventricular assist devices (VADs). Hence, patients with end-stage heart failure (ESHF) and severe renal dysfunction who are not candidates for heart/kidney transplantation (HT/KT) may only be considered for either intermittent hemodialysis (IHD) or hospice. However, there is little evidence about the outcomes of patients with ESHF who are initiated on IHD after VAD implantation. We reviewed the medical charts of all patients in our center who received IHD after VAD implantation. We considered IHD <6-hour sessions 3-4 times weekly, excluding continuous renal replacement therapy (CRRT). Continuous variables were expressed in means and standard deviations, or medians and p25-p75, according to their distribution. Categorical variables were represented in absolute numbers and percentages. Eleven patients (54.1 [±9.9] years of age, 6 [54.6%] women, and 6 [54.6%] African American) underwent VAD implantation as destination therapy (40%) or bridge to transplant (60%) and received IHD. Seven (63.6%) of them received HeartMate II, whereas the other patients were supported with HVAD HeartWare, and HeartMate 3 systems. By the time of VAD implantation, nine (81.8%) patients had history of chronic kidney disease with a median GFR was 60 (45-60) mL/min/1.73 m2 and a mean creatinine was 1.2 (±0.4) mg/dL. The mean outpatient furosemide-dose equivalent prior VAD implantation was 106 (±59.7) mg/day. Ten patients started IHD prior to discharge after VAD placement with a median time from VAD implantation to initiation of IHD was 26 (17-50) days. Another patient was initiated on IHD as outpatient within a year after receiving a VAD. Eight (72.7%) patients died during a follow-up of 886.7 (±762.1) days after initiation of IHD with a median survival time of 838 days. Three patients were bridged to transplantation: 2 HT/KT, and 1 HT (recovered renal function). Details about the timeline of events can be found in Fig 1. Intermittent hemodialysis helped to bridge 2 VAD patients to HT/KT, and another to HT and recovery of renal function. Larger studies could provide valuable insight into this potential strategy to widen the options of advanced heart failure therapies for patients with ESHF. [ABSTRACT FROM AUTHOR]

Background: Small-scale studies focused mainly on nonischemic cardiomyopathy (NICM) have shown that a subset of left ventricular assist device (LVAD) patients can achieve significant improvement of their native heart function, but the impact of ischemic cardiomyopathy (ICM) has not been specifically investigated. Many patients with acute myocardial infarction are discharged from their index hospitalization without heart failure (HF), only to return much later with overt HF syndrome, mainly caused by chronic remodeling of the noninfarcted region of the myocardium.Objectives: This study sought to prospectively investigate the effect of ICM HF etiology on LVAD-associated improvement of cardiac structure and function using NICM as control.Methods: Consecutive patients (n = 154) with documented chronic and dilated cardiomyopathy (ICM, n = 61; NICM, n = 93) requiring durable support with continuous-flow LVAD were prospectively evaluated with serial echocardiograms and right heart catheterizations.Results: In patients supported with LVAD for at least 6 months, we found that 5% of subjects with ICM and 21% of subjects with NICM achieved left ventricular ejection fraction ≥40% (p = 0.034). LV end-diastolic and end-systolic volumes and diastolic function were significantly and similarly improved in patients with ICM and NICM.Conclusions: LVAD-associated unloading for 6 months resulted in a substantial improvement in myocardial structure, and systolic and diastolic function in 1 in 20 ICM and 1 in 5 NICM patients. These specific incidence and timeline findings may provide guidance in clinical practice and research design for sequencing and prioritizing advanced HF and heart transplantation therapeutic options in patients with ICM and NICM. [ABSTRACT FROM AUTHOR]

Data on the efficacy and safety of the combination of warfarin and dual-antiplatelet therapy compared with warfarin and mono-antiplatelet therapy (MAPT) in patients with left ventricular assist devices (LVAD) remains scarce. Single-center study of 130 consecutive patients with durable LVAD. Baseline demographics, antithrombotic and antiplatelet regimen, and outcomes were compared between patients receiving warfarin plus dual-antiplatelet therapy (Group 1) and warfarin plus MAPT (Group 2). Antiplatelet therapy was assessed at hospital discharge post-LVAD implant and included aspirin, clopidogrel and dipyridamole. Outcomes at 1-year were assessed in each group. All patients were on aspirin and warfarin. No significant differences with regards to age, gender or ethnicity were noted at baseline between the two groups. Group 1 was more likely to have higher lactate dehydrogenase LDH levels at discharge and a history of stroke. No significant differences in international normalized ratio INR, hemoglobin or hematocrit were noted at discharge. During the study period, 48 patients had gastrointestinal bleeding events: 28 of 68 (41.2%) in Group 1 vs 20 of 62 (32.2%) in Group 2 (P = 0.293). At 1year, no statistically significant differences were noted in gastrointestinal bleeding (Group 1=27.90% vs Group 2 = 25.80, P = 0.784), ischemic stroke (Group 1 = 8.8% vs group 2 = 6.5%, P = 0.612), hemorrhagic stroke (Group 1 = 4.4% vs group 2 = 3.2%, P = 0.725) or mortality (Group 1 = 5.9% vs Group 2 = 1.6%, P = 0.206). Rates of pump thrombosis however were lower in Group 1 (Group 1 = 0% vs Group 2 = 6.5%, P = 0.033). Our study showed a high prevalence of triple-therapy antithrombotic use in LVAD patients with no significant differences in bleeding, stroke or survival. However, the risk for pump thrombosis was lower at 1-year when compared to patient receiving MAPT. [ABSTRACT FROM AUTHOR]

Coronary angiography remains the gold standard post-transplant screening test for cardiac allograft vasculopathy. This procedure has traditionally been performed via femoral approach. Data on safety and efficacy of radial approach in cardiac transplant patients remains scarce. Single center retrospective study including all cardiac transplant patients who underwent coronary angiography via transradial approach (TRA) or transfemoral approach (TFA). Safety and efficacy outcomes were compared between the 2 groups. Primary end points included major bleeding, vascular complications, crossover to femoral approach, contrast use and radiation exposure. A total of 201 patients were included. 96 patients (47.8%) underwent angiography via TRA. At baseline, no significant differences with regards to age, gender, or traditional risk factors such as HTN, DM, hyperlipidemia were noted between the 2 groups. Most patients underwent intravascular ultrasound (n = 179, 89%) with no statistically significant differences between the 2 groups (TRA: 90.6% vs TFA: 87.6%, P = 0.5). Additionally, there were no statistically significant differences in radiation exposure, amount of contrast use and fluoroscopy time between the 2 groups. Although there were trends toward increased bleeding among TFA group, these were not statistically significant and were mostly driven by access site hematomas. Use of TRA increased over time and Conversion from TRA to TFA was low (n = 4, 4.2%). Coronary angiography via the radial approach in cardiac transplant recipients is feasible, safe and is associated with low a risk of bleeding with no significant increase in radiation exposure when compared to the traditional femoral approach. [ABSTRACT FROM AUTHOR]

Perioperative bleeding in the setting of LVAD implantation adversely impact outcomes. This project aims to determine pre-operative and intraoperative risk factors for this complication. A retrospective cohort study was conducted including 90 consecutive advanced heart failure patients who underwent LVAD implantation as a bridge to transplantation or destination therapy from 2008 to 2017. By protocol, all anti-platelet therapies other than aspirin were discontinued 7 days pre-implantation. Aspirin was continued if clinically indicated. Additionally, any patients on anti-coagulant therapy were transitioned to intravenous heparin. Heparin infusion was discontinued 6 hours pre-operatively. Perioperative hemodynamics, laboratory values, cardiopulmonary bypass parameters, and blood product utilization were collected. Observable bleeding within 7 days of implant occurred in 15 patients (16%). This was significantly associated with the pre-operative use of heparin (OR 6.4; 95% CI 1.8-23.2; p=0.005) and its incidence increased for each 1 mmHg increase in right atrial pressure during pre-operative right heart catheterization (OR 1.1; 95% CI 1.0-1.2; p=0.03). Aspirin use within 3 days of implant increased the need of packed RBC transfusion both intra-operatively (OR 3.2; 95% CI 1.3-8.2; p=0.01) and post-operatively (OR 3.0; 95% CI 1.1-8.4; p=0.04) as well as increased the risk of hemoglobin drop ≥3 gm/dl on post-operative day 1 or the need of more than 2 packed RBC units peri-operatively (OR 4.2; 95% CI 1.6-11.4; p=0.004). Cardiopulmonary bypass time > 60 minutes increased the need for packed RBC transfusion post-operatively (OR 3.07; 95% CI 1.05-9.01; p=0.04). Pre-operative aspirin and heparin are reversible factors that may affect the need for peri-operative blood products transfusion. This may indicate that these agents may need to be withheld longer or alternative antithrombotic preoperative agents should be considered. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to evaluate the diagnostic accuracy of coronary computed tomography angiography (CCTA) for detecting cardiac allograft vasculopathy (CAV) in comparison with conventional coronary angiography (CCAG) alone or with intravascular ultrasound (IVUS). Background: CAV limits long-term survival after heart transplantation, and screening for CAV is performed on annual basis. CCTA is currently not recommended for CAV screening due to the limited accuracy reported by early studies. Technological advances, however, might have resulted in improved test performance and might justify re-evaluation of this recommendation. Methods: A systematic review of Medline, Cochrane, and Embase for all prospective trials assessing CAV using CCTA was performed using a standard approach for meta-analysis for diagnostic test and a bivariate analysis. Results: Thirteen studies evaluating 615 patients (mean age 52 years, 83% male) and 9,481 segments fulfilled inclusion criteria. Patient-based analyses comparing CCTA versus CCAG for the detection of any CAV (> luminal irregularities) and significant CAV (stenosis ≥50%), showed mean weighted sensitivities of 97% and 94%, specificities of 81% and 92%, a negative predictive value (NPV) of 97% and 99%, a positive predictive value (PPV) of 78% and 67%, and diagnostic accuracies of 88% and 94%, respectively. There was a strong trend toward improved sensitivity (97% vs. 91%, p = 0.06) and NPV (99% vs. 97%, p = 0.06) to detect significant CAV with 64-slice compared with 16-slice CCTA. A patient-based analysis of 64-slice CCTA versus IVUS showed a mean weighted sensitivity and specificity of 81% and 75% to detect CAV (intimal thickening >0.5 mm), whereas the PPV and NPV were 93% and 50%, respectively. Conclusions: CCTA using currently available technology is a reliable noninvasive imaging alternative to coronary angiography with an excellent sensitivity, specificity, and NPV for the detection of CAV. [Copyright &y& Elsevier]