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Background: Long-term support with a HeartMate 3 (HM3) left ventricular assist device (LVAD) has improved outcomes of patients with end-stage heart failure. However, there is a paucity of data on the outcomes of patients who underwent concomitant cardiac surgical procedure (CCSP) during HM3-LVAD implantation., Objectives: To assess our single-center experience with patients who underwent CCSP during the implantation of an HM3-LVAD., Methods: From December 2016 until April 2022, 131 adult patients underwent HM3-LVAD implantation. A total of 23 patients underwent CCSP during the HM3-LVAD implantation+CCSP, and 108 underwent only HM3-LVAD implantation (HM3-only)., Results: The median age was 59 ± 11 years (range 54-67), 82% (n=108) were male, and 76% (n=100) were implanted as a bridge-to-transplant. The concomitant procedures performed during the implantation included 8 aortic valve repairs/replacements, 14 tricuspid valve repairs, 4 patent foramen ovales or atrial septal defect closures, and 3 other cardiac procedures. The mean cardiopulmonary bypass time was 113 ± 58 minutes for the HM3-only group and 155 ± 47 minutes for the HM3+CCSP group (P = 0.007). The mortality rates at 30 days, 6 months, and 12 months post-implantation were 2 (9%), 5 (22%), and 6 (26%) respectively for the HM3+CCSP group, and 7 (6%), 18 (17%), and 30 (28%) for the HM3-only group (P = 0.658, 0.554, and 1.000)., Conclusions: Our experience demonstrated no significant difference in the 30-day, 6-month, and 12-month mortality rates for patients who underwent a CCSP during HM3-LVAD implantation compared to patients who did not undergo CCSP during HM3-LVAD implantation.

Objectives: Type 2 diabetes mellitus (DM) is a frequent comorbidity among patients suffering from advanced heart failure necessitating a left ventricular assist device (LVAD) implant. The goal of this study was to evaluate the impact of type 2 DM on early and long-term outcomes of patients following an LVAD implant., Methods: We performed an observational cohort study in a large tertiary care centre in Israel. All data of patients who underwent a continuous flow LVAD implant between 2006 and 2020 were extracted from our departmental database. Patients were divided into 2 groups: group I (patients without diabetes) and group II (patients with diabetes). We compared short-term (30-day and 3-month) mortality, intermediate-term (1- and 3-year) mortality and long-term (5 year) mortality between the 2 groups., Results: The study population included 154 patients. Group I (patients without diabetes) comprised 88 patients and group II (patients with diabetes) comprised 66 patients. The mean follow-up duration was 38.2 ± 30.3 months. Short- and intermediate-term mortality (30 days, 1 year and 3 years) was higher in the group with DM compared with the group without DM but did not reach any statistically significant difference: 16.1% vs 9.8% (P = 0.312), 24.2% vs 17.3% (P = 0.399) and 30.6% vs 21.9% (P = 0.127) respectively. Long-term 5-year mortality was significantly higher in the group with DM compared to the group without: 38.7% vs 24.4% (P = 0.038). Furthermore, predictors of long-term mortality included diabetes (hazard ratio 2.09, confidence interval 1.34-2.84, P = 0.004), as demonstrated by regression analysis., Conclusions: Patients with diabetes and those without diabetes have similar 30-day and short- and intermediate-term mortality rates. The mortality risk of diabetic patients begins to increase 3 years after an LVAD implant. Diabetes is an independent predictor of long-term, 5-year mortality after an LVAD implant., Clinical Trial Registration: Ethical Committee of Sheba Medical Centre, Israel, on 2 December 2014, Protocol 4257., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: While left ventricular assisted devices (LVAD) have revolutionized the treatment of advanced heart failure, they are associated with a wide range of complications, including bleeding and infection which are the most common complications reported in the literature. Our case series report four unusual complications not related to gastrointestinal bleeding and infections and their management., Case Presentation: A 61 year old female after LVAD implantation with late onset of severe symptomatic aortic regurgitation treated by transfemoral transcatheter valve implantation (TAVI) with good long term results. A 75 year old male patient with acute pump failure secondary to cable damage, who underwent urgent pump replacement. A 49 year old female patient with a history of myoma who developed massive uterine bleeding which was treated with emergent open hysterectomy after failed gonadotropin-releasing hormone therapy replacement. A 57 year old male patient with device display failure 1 month after LVAD implantation without the ability to monitor speed, power consumption and blood flow., Conclusions: LVAD patients can be presented with a great variety of complications. Physicians should be aware of their manifestations and the management options.

Background: Primary graft dysfunction (PGD) is a leading cause of early morbidity and mortality after heart transplantation (HT). Statins are known to have immunomodulatory and antiinflammatory effects, and perioperative statin therapy has been associated with reduced cardiovascular complications and improved outcomes after cardiac and noncardiac surgery. Thus, we investigated the influence on PGD of statin therapy administered to recipients before HT., Methods: A retrospective cohort study was conducted on 275 HT recipients assessed from 1997 to 2017; 167 (61%) had received statins during the month prior to and at time of transplantation, whereas 108 (39%) had not. Endpoints included PGD (defined according to the International Society of Heart and Lung Transplantation consensus statement), in-hospital mortality, and 1-year and 5-year survival., Results: PGD incidence was significantly lower for statin-treated patients (21 vs 60%, P < .001). Multivariable analysis demonstrated that pre-HT statin therapy was independently associated with a significant 65% reduced risk for PGD and a 73% reduced risk for in-hospital mortality. One- and five-year mortality, adjusted for age, sex, and amiodarone therapy, were significantly lower for recipients treated with statins (hazard ratio 0.33 and 0.39, 95% confidence interval 0.17-0.63 and 0.22-0.68, respectively; P = .001)., Conclusions: Pre-HT statin therapy was independently associated with a reduced risk for PGD and mortality. Our results also suggested that statins have a beneficial prognostic impact on heart failure patients awaiting HT., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The innovation that has taken place in medicine, combined with state-of-the-art technological developments, provides therapeutic options for patients in conditions that were previously considered incurable. This promotion at the same time presents us with new ethical challenges. In this article, we review the journey through life of an advanced heart failure patient, covering a variety of potential clinical and ethics subjects in the field of heart failure treatment. We review the ethical principles of the Hippocratic Oath against the background of the realities of practicing medicine and of the enormous advances in therapeutics.

Background: Cardiac allograft vasculopathy (CAV) is a major cause of morbidity and mortality following heart transplantation (HT). Reduced cardiovascular mortality and morbidity have been reported in non-HT patients treated with metformin. Given the high prevalence of type 2 diabetes mellitus (T2DM) in HT patients, we investigated the association between metformin therapy and cardiovascular outcomes after HT., Methods: The study population comprised 103 DM patients who had undergone HT between 1994 and 2018 and were prospectively followed-up. We excluded from the study patients with type 1 diabetes mellitus. Fifty-five HT patients (53%) in the cohort were treated with metformin. Clinical data were recorded on prospectively designed forms. The primary outcomes included CAV, survival, and the combined end-point of CAV or cardiovascular mortality., Results: Kaplan-Meier survival analysis showed that the CAV rate at 20 years of follow-up was lower in DM patients treated with metformin than in those who were not (30 vs. 65%; log-rank p = 0.044). Similarly, the combined risk of CAV or cardiovascular mortality was lower in the metformin-treated patients than in those not receiving metformin (32 vs. 68%; log rank p = 0.01). Consistently, multivariate analysis adjusted for age and comorbidities showed that metformin therapy was independently associated with a significant 90% reduction (95% confidence interval 0.02-0.46, p = 0.003) in the risk for the development of CAV, and a 91% reduction (95% confidence interval 0.02-0.42; p = 0.003) in the risk for CAV or cardiovascular mortality., Conclusions: In diabetic HT patients, metformin therapy is independently associated with a significant reduction in the long-term risk for CAV and the combined end-point of CAV or cardiovascular mortality after HT.

Left ventricular assist device (LVAD) implantation is a common procedure in patients with end-stage heart failure. Although optimal fluid management is essential for acceptable postoperative treatment, it is critical to identify which patients will benefit from fluid administration. Passive leg raising (PLR) is a validated dynamic method that predicts fluid responsiveness in patients with heart failure by inducing a transient increase in cardiac preload. We performed a prospective study on 20 consecutive patients who underwent PLR maneuvers after LVAD implantation. Left ventricular assist device flow, end-tidal carbon dioxide, central venous pressure (CVP), and mean arterial pressure (MAP) were measured before and after PLR. Passive leg raising responsiveness was defined as at least a 15% increase in LVAD flow: (11 were responders and 9 nonresponders). Of the responders, 7 had right ventricular dysfunction (≥3). Passive leg raising responsiveness was associated with an increase of 19% in the LVAD flow, the mean CVP was raised from 11.3 to 14.4 mm Hg and the MAP from 82.6 to 86.7 mm Hg. After PLR, end-tidal carbon dioxide was increased by 4.6 mm Hg in the responders and 1.1 mm Hg in the nonresponders. The PLR maneuver is a noninvasive and easy to perform method that uses LVAD flow to assess fluid responsiveness in patients with heart failure after LVAD implantation.

Heart failure (HF) poses a major health burden worldwide, and early detection of at-risk populations is of clinical importance. The triglyceride-glucose index (TGI), a surrogate marker of insulin resistance, is thought to be associated with a higher risk of developing cardiovascular disease. Nonetheless, its predictive value for the future development of HF in healthy populations is unknown. We thus investigated the utility of TGI for the prediction of HF development in healthy adults. The study population comprised 19,829 self-referred adults, evaluated annually in a screening program, who were free of baseline diabetes and cardiovascular disease. The TGI was calculated as: ln[fasting triglycerides (mg/dL) × fasting glucose (mg/dL)/2]. The primary end-point was the development of any HF. An HF specialist classified all HF events in accordance with guidelines. The mean age was 50±8 years for the cohort, 14,039 (71%) were men, and 2,709 (14%) were obese. Baseline TGI was 8.53±0.54. During a median follow-up of 14 years (IQR 8-18), 193 (1%) subjects developed HF. Univariate Cox regression showed that each 1 unit increase in TGI was associated with a significant 67% increased risk of developing any HF during follow-up (95% CI 1.30-2.16, p<.001). A multivariate model, adjusted for age, sex, baseline hypertension, LDL, obesity, and fitness level consistently showed that each 1 unit increase in TGI was associated with a 39% increased risk of developing HF (95% CI 1.05-1.84, p=.020). The association between the baseline TGI and the development of HF was obesity dependent, such that for obese patients each 1 unit increase in TGI was associated with a significant 61% increase in the risk of HF (95% CI 1.18-2.20, p=.003), while for non-obese subjects the association was non-significant (p NS; p for interaction.018). High TGI in the healthy adult population is associated with an increased risk of HF and is a promising potential marker for the later development of HF. The impact of interventions aiming to decrease TGI on HF outcomes should be assessed. [ABSTRACT FROM AUTHOR]

The definition of antibody-mediated rejection (AMR) now recognizes that AMR is a spectrum of immunologic injury ranging from subclinical, histological, immunologic and/or serological findings without graft dysfunction to overt AMR with hemodynamic compromise. The decision to treat AMR takes into account the clinical evidence of rejection, e.g., symptoms or evidence of graft dysfunction, but the definition of hemodynamic/clinical compromise lacks uniformity and no specific criteria are defined. We describe a case report suggesting that carbohydrate antigen 125 (CA125) could be used as a marker for diagnosing clinically significant AMR and for guidance of therapy. A 43 y/o woman, 14 months post-heart transplantation, presented at a routine follow-up with unexplained new sinus tachycardia; otherwise, she was clinically asymptomatic. A recent annual evaluation had revealed normal invasive hemodynamics and coronaries, and no donor specific antibodies (DSAs). Over the next 2 days ECHO deteriorated, with the development of acute severe biventricular dysfunction, although she was "apparently" clinically asymptomatic. Endomyocardial biopsy was classified as pAMR1(H+), ISHLT 1R. De novo DSAs (Class I & II) were detected. Therapy consisted of pulse steroids, followed by thymoglobulin, plasmapheresis, immunoglobulins, rituximab, & photopheresis. Rapidly progressive hemodynamic compromise necessitated ECMO support. Over the following months she developed clinical overt right heart failure, but she gradually recovered fully. CA125 at presentation and through the clinical course and follow up correlated highly with the invasive hemodynamics, ECHO indices, and the clinical course (Figure 1). With the recognition of the importance of AMR, there is a need for criteria defining the clinical scenario. The current case suggests that CA125 is a potential marker for clinical significance and could play a role in the guidance of therapy. [ABSTRACT FROM AUTHOR]

Elevated carbohydrate antigen 125 (CA125) correlates with serosal effusions and has previously been thought to be associated with the clinical severity of heart failure (HF) and fluid congestion. We assessed CA125 as a predictor of hemodynamics and investigated the additive prognostic benefit of B-type natriuretic peptide (BNP). Between 2015-2019, 235 patients hospitalized for HF were prospectively assessed for CA125 and BNP serum levels simultaneously with echocardiography and right heart study. CA125 correlated positively with intracardiac pressures and inversely with cardiac index (CI). The strongest correlation was for right atrial pressure (RAP) (ρ = 0.82, p<0.001). CA125 >42 U/mL had a sensitivity of 95.8% and specificity of 95.3% for the prediction of RAP ≥11 mmHg. The predictive accuracy of CA125 vs BNP was superior for RAP (AUC 0.99 vs 0.84, p<0.001) and right ventricular (RV) pressure (AUC 0.99 vs 0.82, p<0.001), but BNP was better for the prediction of pulmonary capillary wedge pressure (AUC 0.95 vs 0.82, p<0.001) and CI (AUC 0.92 vs 0.84, p=0.03). Elevated CA125 was independently associated with increased right heart pressures, while BNP with left-sided filling pressures and lower CI (p<0.05). Combining CA125 and BNP values delineated 4 distinct HF congestion phenotypes (Figure): high CA125-high BNP - reduced ejection fraction (HFrEF) with RV dysfunction; low CA125-high BNP - HFrEF with preserved RV function; and high CA125-low BNP and low CA125-low BNP - preserved EF, with and without RV dysfunction, respectively. CA125 predicts and quantifies right heart function and hemodynamic. CA125-BNP congestion phenotypes can be used as a guidance for diagnosis (improved diagnosis of HFpEF and delineation of congestion status) and therapy (LVAD candidate selection and individualized drug therapies and titration). [ABSTRACT FROM AUTHOR]