Search

Aims Optimal blood pressure (BP) control is imperative to reduce complications, especially strokes, in continuous flow ventricular assist device (VAD) patients. Doppler BP has been shown to be an accurate and reliable non‐invasive BP measurement method in HeartMate II and HVAD patients. We examined whether Doppler BP is also accurate in patients with the HeartMate 3 VAD. Methods and results In a prospective, longitudinal cohort of HeartMate 3 patients, arterial line BP and simultaneously measured Doppler opening pressure were obtained. Correlation and agreement between Doppler opening pressure and arterial line mean arterial pressure (MAP) versus systolic blood pressure (SBP) were analysed, as well as the effect of pulse pressure on the accuracy of Doppler opening pressure. A total of 589 pairs of simultaneous Doppler opening pressure and arterial line pressure readings were obtained in 43 patients. Doppler opening pressure had good correlation with intra‐arterial MAP (r = 0.754) and more closely approximated MAP than SBP (mean error 2.0 vs. −8.6 mmHg). Pulse pressure did not have a clinically significant impact on the accuracy of the Doppler BP method. These results in HeartMate 3 patients are very similar to previous results in HeartMate II and HVAD patients. Conclusions Doppler BP method should be the default non‐invasive BP measurement method in continuous flow VAD patients including patients implanted with the HeartMate 3.

Heart failure (HF) manifests as a severe functional limitation and myriad physiological derangements. Divining signals from this milieu is the domain of the HF specialist among whom there is an indelible belief that more effective HF care intrinsically arises from more communication, more measurement and, increasingly, more complex methods of acquiring and processing patient-generated data. Mobile technologies and electronically integrated systems of care eem to facillitate perfectly the steps of data generation, transmission, synthesis, interpretation, action and, ultimately, benefit to the patient. Unfortunately, realising improved outcomes among persons with HF enabled by outpatient monitoring has been elusive. In this issue of Heart , Rahimi et al 1 present results of a randomised trial designed to test whether centralised decision support optimised medical therapies and improved quality of life among patients compared with monitoring without centralised decision support. This hypothesis is of paramount importance. The authors’ study employs state-of-the-art blinding, randomisation, endpoint measurement and analysis to maximise the validity of their study. Nonetheless, the study ultimately could not conclude that expert support and alerts improved the primary outcome of medication use and dosing and quality of life compared with monitoring alone. The weighted change in medication optimisation demonstrated an improvement of 3% in the control group and 8% in the intervention group (p=0.20) …

Highly specialized left ventricular assist device care is not readily available in many areas, potentially limiting access to therapy. This retrospective analysis examines the relationship of outcomes by patient distance from implanting left ventricular assist device center within the Mechanical Circulatory Support Research Network. Zip codes were used to calculate patient distance, with the primary outcome of interest being 3-year survival by distance from the surgical center. Secondary outcomes included 90-day survival and incident event rates for the following: gastrointestinal bleeding, infection, cerebral event, and pump thrombosis. Across the four centers, there were 1184 patients supported for a median of 486 days. Overall survival was 91 ± 0.8% at 90 days and 61 ± 1.9% at 3 years, with worse 3-year survival in those living >90 vs. ≤90 miles from the ventricular assist device implant center (55 ± 3.0% vs. 64 ± 2.5, p = 0.019). Patients living >90 miles from an implant center were older, more likely to be implanted for destination therapy support, had a prior sternotomy, and had worse renal function than those living closer (p

Mechanical circulatory support (MCS) has markedly improved the likelihood of transplant among patients with advanced heart failure. Transplant survival following MCS is similar for supported and unsupported recipients. Transplant survival is only reduced following left ventricle assist device (LVAD) support complicated by infection, total artificial heart support, and extracorporeal life support. Despite allosensitization and a higher incidence of vasoplegia syndrome, posttransplant survival for durable LVADs is similar to patients with inotropes alone at the time of transplant. MCS as a bridge to transplant offers significant benefits over waiting without support.

Objectives This study sought to assess the impact of implantable cardioverter-defibrillators (ICDs) on waitlist mortality in patients listed for heart transplantation (HT). Background The impact of ICDs on preventing sudden cardiac death in patients awaiting HT has not been studied in large multicenter cohorts. Furthermore, whether ICDs benefit patients with a left ventricular assist device (LVAD) is unknown. Methods Adults (age ≥18 years) listed for first-time HT in the United States between January 1, 1999, and September 30, 2014, were retrospectively identified from the United Network for Organ Sharing registry. The primary predictor variable was the presence of an ICD at the time of listing. Primary outcome variable was all-cause waitlist mortality. Results Data on 32,599 patients (mean age 53 ± 12 years, 77% male, 70% Caucasian) were analyzed. During median follow-up of 154 days, 3,638 patients (11%) died on the waitlist (9% in ICD group vs. 15% in no-ICD group; p Conclusions ICD use was associated with improved survival on the HT waitlist in patients with or without LVADs. These findings strengthen the current guideline recommendations of using ICDs in nonhospitalized patients awaiting HT and provide new insight into the effectiveness of ICDs on survival in LVAD-supported patients.

Introduction Survival is nearly 50% after 5 years of LVAD support. While preop variables can predict short-term (ST) survival, correlates of long term (LT) survival remain poorly characterized. Hypothesis We hypothesize that preop risk stratification will be limited to predicting ST survival and not LT success. Method Patients (n=16474) undergoing LVAD implant (2012-18) in Intermacs-STS were grouped according to time on support: ST ( Results Of those alive on LVAD support at 1 Y, the 3, 5, and 6 Y survivals were 75%, 53%, and 45%, respectively. Patients who were alive on LVAD support at 3 Ys had survivals of 60% at 6 Ys. The table shows adjusted associations between clinical variables and mortality for the MT and LT survival groups starting at 1 and 3 Ys, respectively. For the MT group, older, obese and Caucasian patients and those with preop RV dysfunction, active smoking, unmarried status or comorbidities had higher mortality after 1 Y of support. The occurrence of postop malnutrition, renal, and hepatic dysfunction also increased mortality. Finally, each episode of stroke, device infection or device malfunction increased mortality by 13-42%. For the LT group, postop organ dysfunction and malnutrition impacted extended LVAD survival and mortality increased by 10-46% per adverse event. The only preop correlates of survival beyond 3 Ys were older age, Caucasian race, and history of CABG. Conclusion The success of LVAD support hinges on achieving LT survival. In operative survivors, LT LVAD survival is heavily constrained by the occurrence of events after LVAD placement. Preop, this also limits our ability to provide individualized, LT survival estimates.

Purpose The heart allocation system allocates hearts based on geographic distance between donor and transplant centers, blood type and severity of illness. The Donor Service Area (DSA) designation and fixed distance radii may be abolished if a continuous allocation is implemented. This study sought to assess whether donor heart allocation within the DSA is associated with a survival benefit. Methods Heart transplant recipients between 2010 and 2018 were identified in the Organ Procurement and Transplant Network (OPTN). Following adjustment for the expected post-transplant graft survival, a Bayesian logistic regression model was used to assess the effect of DSA versus extra-DSA allocation of donor hearts. The primary outcome was one-year graft survival adjusted for risk of graft failure using the Scientific Registry of Transplant Recipient's (SRTR) January 2019 adjustment model. Results Locally allocated donor hearts were more likely younger and gender matched and had lower prevalence of donor diabetes and smoking when compared to those imported from another DSA (Table 1). The proportion of locally shared organs between regions varied significantly (p Conclusion Following adjustment for recipient and donor factors, we found that allocation of organs within the DSA did not reduce one-year graft failure rates.

We describe how patient characteristics influence hospital bypass, interhospital transfer, and in-hospital mortality in patients with heart failure in Washington. Rural patients with heart failure may bypass their nearest hospital or be transferred for appropriate therapies. The frequency, determinants, and outcomes of these practices remain uncharacterized.Mean excess travel times based on hospital and patient residence ZIP codes were calculated using published methods. Hospitals and servicing areas were coded based on bed size and ZIP code, respectively. Transfer patterns were analyzed using bootstrap inference for clusters. Analysis of mortality and transfer-associated factors was performed using logistic regression with generalized estimating equations. There were 48,163 patients, representing 1106 instances of transfer, studied. The mean excess travel time increased 7.14 minutes per decrease in population density (metropolitan, micropolitan, small town, rural; P.0001). The rural mean excess travel time was greatest at 28.56 minutes. Transfer likelihood increased with younger age, male gender, admitting hospital rurality, higher Charlson Comorbidity Index, and stroke. Transfer was less likely among women (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.72-0.94) and patients over 70 years old (OR, 0.15-0.46; 95% CI, 0.10-0.65). Adjusting for comorbidities and transfer propensity, transfer exhibited a stronger association with mortality than any other measured patient risk factor (OR, 2.15; 95% CI, 1.69-2.73), excluding stroke (OR, 7.09; 95% CI, 4.99-10.06).Rural hospital bypass is prevalent among patients with heart failure, although its clinical significance is unclear. Female and older patients were found to have a lesser likelihood of transfer adjusted for other factors. Interhospital transfer is associated with increased mortality when adjusted for comorbidities.

BACKGROUND: Patients with heart failure having a low expected probability of arrhythmic death may not benefit from implantable cardioverter defibrillators (ICDs). OBJECTIVE: The objective was to validate models to identify cardiac resynchronization therapy (CRT) candidates who may not require CRT devices with ICD functionality. METHODS: Heart failure (HF) patients with CRT-Ds and non-CRT ICDs from the National Cardiovascular Data Registry and others with no device from 3 separate registries and 3 heart failure trials were analyzed using multivariable Cox proportional hazards regression for survival with the Seattle Heart Failure Model (SHFM; estimates overall mortality) and the Seattle Proportional Risk Model (SPRM; estimates proportional risk of arrhythmic death). RESULTS: Among 60,185 patients (age 68.6±11.3 years, 31.9% female) meeting CRT-D criteria, 38,348 had CRT-Ds, 11,389 had non-CRT ICDs, and 10,448 had no device. CRT-D patients had a prominent adjusted survival benefit (HR 0.52, 95% CI 0.50–0.55, pmedian had substantially more ICD-attributable benefit (absolute risk reduction of 2.6%/year combined; p

Background The number of adult congenital heart disease (CHD) patients undergoing heart transplantation is increasing rapidly. CHD patients have higher surgical risk at transplantation. High-volume adult CHD transplant centers may have better transplant outcomes. Objectives This study aimed to evaluate the effect of center CHD transplant volume and expertise on transplant outcomes in CHD patients. Methods The authors studied heart transplantations in CHD patients age ≥18 years using the United Network of Organ Sharing (UNOS) database for the primary outcomes of waitlist mortality and post-transplant outcomes at 30 days and 1 year. Transplant centers were assessed by status as the highest CHD transplant volume center in a UNOS region versus all others, presence of Adult Congenital Heart Association accreditation, and adult versus pediatric hospital designation. Results Between January of 2000 and June of 2018, 1,746 adult CHD patients were listed for transplant; 1,006 (57.6%) of these underwent heart transplantation. After adjusting for age, sex, listing status, and inotrope requirement, waitlist mortality risk was lower at Adult Congenital Heart Association accredited centers (hazard ratio: 0.730; p = 0.020). Post-transplant 30-day mortality was lower at the highest volume CHD transplant center in each UNOS region (hazard ratio: 0.706; p = 0.014). Conclusions Designated expertise in CHD care is associated with improved waitlist outcomes for CHD patients listed for transplantation. Post-transplant survival was improved at the highest volume regional center. These findings suggest a possible advantage of regionalization of CHD transplantation.

Aims Heart failure (HF) is associated with an increased risk of sudden cardiac death (SCD). This study sought to demonstrate the incidence of SCD within a multicentre Japanese registry of HF patients hospitalized for acute decompensation, and externally validate the Seattle Proportional Risk Model (SPRM). Methods and results We consecutively registered 2240 acute HF patients from academic institutions in Tokyo, Japan. The discrimination and calibration of the SPRM were assessed by the c-statistic, Hosmer–Lemeshow statistic, and visual plotting among non-survivors. Patient-level SPRM predictions and implantable cardioverter-defibrillator (ICD) benefit [ICD estimated hazard ratio (HR), derived from the Cox proportional hazards model in the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT)] was calculated. During the 2-year follow-up, 356 deaths (15.9%) occurred, which included 76 adjudicated SCDs (3.4%) and 280 non-SCDs (12.5%). The SPRM showed acceptable discrimination [c-index = 0.63; 95% confidence interval (CI) 0.56–0.70], similar to that of original SPRM-derivation cohort. The calibration plot showed reasonable conformance. Among HF patients with reduced ejection fraction (EF; < 40%), SPRM showed improved discrimination compared with the ICD eligibility criteria (e.g. New York Heart Association functional Class II–III with EF ≤ 35%): c-index = 0.53 (95% CI 0.42–0.63) vs. 0.65 (95% CI 0.55–0.75) for SPRM. Finally, in the subgroup of 246 patients with both EF ≤ 35% and SPRM-predicted risk of ≥ 42.0% (SCD-HeFT defined ICD benefit threshold), mean ICD estimated HR was 0.70 (30% reduction of all-cause mortality by ICD). Conclusion The cumulative incidence of SCD was 3.4% in Japanese HF registry. The SPRM performed reasonably well in Japanese patients and may aid in improving SCD prediction.

Adult Congenital Heart Disease (ACHD) heart transplant recipients may have lower than average post-transplant survival as a result of higher peri-operative mortality than non-ACHD patients, but they also have a decreased incremental late mortality risk. However, long-term survival between groups has

The prevalence of ventricular assist device (VAD) therapy has continued to increase due to a stagnant donor supply and growing advanced heart failure (HF) population. We hypothesize that left ventricular (LV) size strongly influences biocompatibility and risk of thrombosis. Unsteady computational fluid dynamics (CFD) was used in conjunction with patient-derived computational modeling and virtual surgery with a standard, apically implanted inflow cannula. A dual-focus approach of evaluating thrombogenicity was employed: platelet-based metrics to characterize the platelet environment and flow-based metrics to investigate hemodynamics. Left ventricular end-diastolic dimensions (LVEDds) ranging from 4.5 to 6.5 cm were studied and ranked according to relative thrombogenic potential. Over 150,000 platelets were individually tracked in each LV model over 15 cardiac cycles. As LV size decreased, platelets experienced markedly increased shear stress histories (SHs), whereas platelet residence time (RT) in the LV increased with size. The complex interplay between increased SH and longer RT has profound implications on thrombogenicity, with a significantly higher proportion of platelets in small LVs having long RT times and being subjected to high SH, contributing to thrombus formation. Our data suggest that small LV size, rather than decreased VAD speed, is the primary pathologic mechanism responsible for the increased incidence of thrombosis observed in VAD patients with small LVs.

The authors previously developed the Seattle Proportional Risk Model (SPRM) in systolic heart failure patients without implantable cardioverter-defibrillators (ICDs)to predict the proportion of deaths that were sudden. They subsequently validated the SPRM in 2 observational ICD data sets. The objectives in the present study were to determine whether this validated model could improve identification of clinically important variations in the expected magnitude of ICD survival benefit by using a pivotal randomized trial of primary prevention ICD therapy.Recent data show that 50% of nominally eligible subjects receive guideline- recommended primary prevention ICDs.In the SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial), a placebo-controlled ICD trial in 2,521 patients with an ejection fraction ≤35% and symptomatic heart failure, we tested the use of patient-level SPRM-predicted probability of sudden death (relative to that of non-sudden death) as a summary measurement of the potential for ICD benefit. A Cox proportional hazards model was used to estimate variations in the relationship between patient-level SPRM predictions and ICD benefit.Relative to use of mortality predictions with the Seattle Heart Failure Model, the SPRM was much better at partitioning treatment benefit from ICD therapy (effect size was 2- to 3.6-fold larger for the ICD×SPRM interaction). ICD benefit varied significantly across SPRM-predicted risk quartiles: for all-cause mortality, a +10% increase with ICD therapy in the first quartile (highest risk of death, lowest proportion of sudden death) to a decrease of 66% in the fourth quartile (lowest risk of death, highest proportion of sudden death; p = 0.0013); for sudden death mortality, a 19% reduction in SPRM quartile 1 to 95% reduction in SPRM quartile 4 (p 0.0001).In symptomatic systolic heart failure patients with a Class I recommendation for primary prevention ICD therapy, the SPRM offers a useful patient-centric tool for guiding shared decision making.

Multivariable risk scores and exercise measures are well-validated risk prediction methods. Combining information from a functional evaluation and a risk model may improve accuracy of risk predictions. We analyzed whether adding exercise measures to the Seattle Heart Failure Model (SHFM) improves risk prediction accuracy in systolic heart failure.We used a sample of patients from the Heart Failure and A Controlled Trial Investigating Outcomes of Exercise TraiNing (HF-ACTION) study (http://www.clinicaltrials.gov; unique identifier: NCT00047437) to examine the addition of peak oxygen consumption, expired volume per unit time/volume of carbon dioxide slope, 6-minute walk distance, or cardiopulmonary exercise duration to the SHFM. Multivariable Cox proportional hazards models were used to test the association between the combined end point (death, left ventricular assist device, or cardiac transplantation) and the addition of exercise variables to the SHFM.The sample included 2,152 patients. The SHFM and all exercise measures were associated with events (all p0.0001) in proportional hazards models. There was statistically significant improvement in risk estimation when exercise measures were added to the SHFM. However, the improvement in the C index for the addition of peak volume of oxygen consumption (+0.01), expired volume per unit time/volume of carbon dioxide slope (+0.02), 6-minute walk distance (-0.001), and cardiopulmonary exercise duration (+0.001) to the SHFM was small or slightly worse than the SHFM alone. Changes in risk assignment with the addition of exercise variables were minimal for patients above or below a 15% 1-year mortality.Exercise performance measures and the SHFM are independently useful for predicting risk in systolic heart failure. Adding cardiopulmonary exercise testing measures and 6MWD to the SHFM offers only minimal improvement in risk reassignment at clinically meaningful cut points.

Precise risk stratification in heart failure (HF) patients enables clinicians to tailor the intensity of their management. The Seattle Heart Failure Model (SHFM), which uses conventional clinical variables for its prediction, is widely used. We aimed to externally validate SHFM in Japanese HF patients with a recent episode of acute decompensation requiring hospital admission.SHFM was applied to 2470 HF patients registered in the West Tokyo Heart Failure and National Cerebral And Cardiovascular Center Acute Decompensated Heart Failure databases from 2006 to 2016. Discrimination and calibration were assessed with the use of the c-statistic and calibration plots, respectively, in HF patients with reduced ejection fraction (HFrEF;40%) and preserved ejection fraction (HFpEF; ≥40%). In a perfectly calibrated model, the slope and intercept would be 1.0 and 0.0, respectively. The method of intercept recalibration was used to update the model. The registered patients (mean age 74 ± 13 y) were predominantly men (62%). Overall, 572 patients (23.2%) died during a mean follow-up of 2.1 years. Among HFrEF patients, SHFM showed good discrimination (c-statistic = 0.75) but miscalibration, tending to overestimate 1-year survival (slope = 0.78; intercept = -0.22). Among HFpEF patients, SHFM showed modest discrimination (c-statistic = 0.69) and calibration, tending to underestimate 1-year survival (slope = 1.18; intercept = 0.16). Intercept recalibration (replacing the baseline survival function) successfully updated the model for HFrEF (slope = 1.03; intercept = -0.04) but not for HFpEF patients.In Japanese acute HF patients, SHFM showed adequate performance after recalibration among HFrEF patients. Using prediction models to tailor the care for HF patients may improve the allocation of medical resources.

Background: As heart failure prevalence continues to increase in the setting of a static donor supply, left ventricular assist device (LVAD) therapy for end-stage heart failure continues to grow. Anecdotal evidence suggests that malalignment of the LVAD inflow cannula may increase thrombosis risk, but this effect has not been explored mechanistically or quantified statistically. Our objective is to elucidate the impact of surgical angulation of the inflow cannula on thrombogenicity. Methods and Results: Unsteady computational fluid dynamics is used in conjunction with computational modeling and virtual surgery to model flow through the left ventricle for 5 different inflow cannula angulations. We use a holistic approach to evaluate thrombogenicity: platelet-based (Lagrangian) metrics to evaluate the platelet mechanical environment, combined with flow-based (Eulerian) metrics to investigate intraventricular hemodynamics. The thrombogenic potential of each LVAD inflow cannula angulation is quantitatively evaluated based on platelet shear stress history and residence time. Intraventricular hemodynamics are strongly influenced by LVAD inflow cannula angulation. Platelet behavior indicates elevated thrombogenic potential for certain inflow cannula angles, potentially leading to platelet activation. Our analysis demonstrates that the optimal range of inflow angulation is within 0±7° of the left ventricular apical axis. Conclusions: Angulation of the inflow cannula >7° from the apical axis (axis connecting mitral valve and ventricular apex) leads to markedly unfavorable hemodynamics as determined by computational fluid dynamics. Computational hemodynamic simulations incorporating Lagrangian and Eulerian metrics are a powerful tool for studying optimization of LVAD implantation strategies, with the long-term potential of improving outcomes.

Objectives In this study, the authors developed the Seattle Proportional Risk Model (SPRM) to estimate the proportion of total mortality due to sudden death. We prospectively validated the model in HF-ACTION (Participants in Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) and tested whether the implantable cardioverter-defibrillator (ICD) benefit varied with the SPRM. Background Prediction of which heart failure patients are most likely to die of sudden death versus nonsudden death is an important factor in determining who will benefit the most from an ICD. Methods Among 2,331 patients enrolled, 1,947 patients were retained for analysis over a median follow-up of 2.5 years. The SPRM was calculated using age, gender, diabetes, body mass index, systolic blood pressure, ejection fraction, New York Heart Association functional class, sodium, creatinine, and digoxin use. Results An ICD (ICD or CRT-D) was in use before death in 1,204 patients (62%). SPRM was predictive of sudden death versus nonsudden death in those without an ICD (p = 0.002). The hazard ratio representing ICD versus no ICD was 0.63 for all-cause mortality (p = 0.0002). The ICD benefit varied with the SPRM for all-cause mortality (p = 0.001), with a greater benefit in those with a higher conditional probability of sudden death. Conclusions In population of ambulatory patients with a New York Heart Association functional class II-IV HF and ejection fraction of ≤35%, the SPRM was predictive of the proportional risk of sudden versus nonsudden death. ICDs were associated with a decreased risk of all-cause mortality by 37% and the ICD benefit varied with the SPRM. The SPRM may be useful in risk stratifying patients for a primary prevention ICD. (Exercise Training Program to Improve Clinical Outcomes in Individuals With Congestive Heart Failure; NCT00047437 )

Purpose The resistance compliance (RC) time describes the relationship between the pulmonary vascular resistance (PVR) and the pulmonary artery compliance (PAC) reflecting right ventricular (RV) afterload. Increased left atrial pressure shifts this relationship, lowering PAC for any given PVR leading to ventricular-arterial uncoupling and increased RV afterload. We hypothesize that decreased RC time is associated with increased in-hospital mortality due to poor right heart compensation in acute shock. Methods Admission right heart catheterization (RHC) data were analyzed in consecutive patients from 2014 to 2016 with cardiogenic shock as defined by a cardiac index Results We studied 235 patients with 265 unique encounters, where 15.3% died during the hospitalization. The mean RC time in our study sample was 0.33 (SD ±0.21). The hazard ratio (HR) for in-hospital mortality risk with the RC time was 0.161 (p-value = 0.07). Compared to the highest tertile, the lowest tertile of RC time was associated with increased mortality (HR 0.323, p-value = 0.045). The mortality risk persisted when adjusted for the RAP (HR 0.344, p-value = 0.056). The mean PAPi was 3.08 (SD ±3.79). The HR of in-hospital mortality with the PAPi was 0.806 (p-value = 0.166). Compared to the highest tertile, the lowest tertile of PAPi was associated with an increased mortality (HR 0.382, p-value = 0.045). This association was non-significant when adjusted for the RAP (HR 0.461, p-value = 0.202). Conclusion We demonstrate that a low RC time and increased RV afterload is associated with increased mortality in patients admitted with cardiogenic shock. In contrast to the PAPi, this association is independent of right atrial pressure, suggesting that the RC time may be a better marker of outcomes independent of central venous pressure. Further studies are needed to evaluate the role of these markers in cardiogenic shock.

There are rare reports in the literature of bortezomib induced cardiotoxicity. We report a presentation of fulminant myocarditis due to bortezomib. A 53 year old male with recent diagnosis of multiple myeloma, on lenalidomide, bortezomib, and dexamethasone, presents to the ER with chest pain. ECG

The digitalis glycosides (digoxin) have been ensconced by history, efficacy, therapeutic necessity, and lack of definitive evidence as treatments for both heart failure (HF) and atrial fibrillation (AF). There is a reluctance to abandon digoxin because of its perceived ability to additively improve

The development of new aortic insufficiency after a period of support with a left ventricular assist device can result in progressive heart failure symptoms. Transcatheter aortic valve repair can be an effective treatment in selected patients, but the lack of aortic valve calcification can result in unstable prostheses or paravalvular leak. We describe a technique of deploying a self-expanding CoreValve (Medtronic, Minneapolis, MN, USA) into the aortic annulus, followed by a balloon-expandable SAPIEN-3 (Edwards, Irvine, CA, USA).

The Seattle Heart Failure Model (SHFM) is a multivariable model with proven prognostic value. Cardiopulmonary exercise testing (CPX) and neurohormonal markers (eg, B-type natriuretic peptide [BNP]) are also well accepted assessment techniques in the HF population and have both demonstrated robust prognostic value. The purpose of this investigation was to assess the combined prognostic value of the SHFM and CPX.This study included all 453 patients enrolled in the Multicenter In-Sync Randomized Clinical Evaluation (MIRACLE) trial. Baseline SHFM and CPX were used. Both peak oxygen consumption (VO(2)) and ventilatory efficiency (VE/VCO(2)) were determined. In a univariate Cox proportional model analysis, SHFM and log-transformed peak VE/VCO(2) were stronger predictors of 6-month mortality (both P .001) than log-transformed BNP (P = .013) or peak VO(2) (P = .066). In a multivariable Cox proportional hazards model, neither peak VO(2) nor BNP were independent predictors when added to the SHFM (P .1). Conversely, peak VE/VCO(2) was a strong independent predictor when added to the SHFM, with an increase in the Cox proportional hazards model Wald χ(2) from 22.7 for SHFM alone to 33.8 with inclusion of log-transformed peak VE/VCO(2) (P .0001) and significant changes in the net reclassification improvement and integrated discrimination index (both P .002).These results indicate that the SHFM and peak VE/VCO(2) work synergistically to improve prognostic resolution. Further investigation is needed to continue to optimize multivariable prognostic models in patients with HF, a chronic disease population that continues to suffer from a high adverse event rate despite advances in medical care.

In this study we investigated whether the addition of peak oxygen consumption (VO(2)) improves the predictive accuracy of the Seattle Heart Failure Model (SHFM). The SHFM is a validated multivariate risk model that uses NYHA classification to assess functional capacity rather than peak oxygen consumption (VO(2)).Outpatients (n = 1,240) evaluated for transplant at three centers had their SHFM score calculated and peak VO(2) measured. The outcomes assessed were death/LVAD/urgent transplant with censoring at the time of elective transplant.Over the course of 4.0 (mean) years of observation, there were 571 events. Both the SHFM score (χ(2) = 227) and peak VO(2) (χ(2) = 88, both p0.0001) were highly predictive of outcomes. The SHFM and peak VO(2) were modestly correlated (r = 0.39, p0.0001). In a multivariate Cox model, peak VO(2) added to the SHFM with a hazard ratio of 0.949 (p0.0001) for each 1-ml/kg/min increase. Peak VO(2) improved both the net reclassification improvement and integrated discrimination index (both p ≤ 0.0002). Peak VO(2) provided additive prognostic information within each SHFM score (p0.05). The 1-year areas under the receiver-operating characteristic curve were obtained for peak VO(2) (0.645, 95% CI 0.606 to 0.684), SHFM (0.758, 95% CI 0.721 to 0.795) and SHFM with peak VO(2) (0.766, 95% CI 0.731 to 0.802). The SHFM-predicted vs actual survival free of LVAD/UNOS Status 1 transplant at 1 year (86% vs 83%) and 4 years (63% vs 63%) were similar.The multivariate SHFM is a powerful predictor of death/LVAD/urgent transplant. Peak VO(2) adds prognostic information across the spectrum of the SHFM, but changes in decision regarding transplant listing occur mainly in moderate-risk patients.

Objective We sought to develop a 3D printing based simulator for teaching extended septal myectomy to trainees in cardiothoracic surgery (clinical PGY 4-7). This operation is difficult to teach given generally unfamiliar and highly variable anatomy, limited visibility for the assistant, and significant potential complications. Methods A curriculum utilizing multimedia didactics and 3D print based patient-specific surgical simulation was implemented. Six identical 3D prints were constructed for each of 5 consecutive patients. Pre-operative septal myectomy was performed on each printed heart by an attending surgeon and 5 residents. Model myectomy specimen volumes were measured by liquid displacement. All print resections were videotaped and blindly evaluated by 3 attending surgeons. Pre- and post-test evaluations, and a survey tool were also used to evaluate the curriculum. Results Baseline myectomy resection volumes differed significantly (Attending 15 cm 3 vs Resident 3.1 cm 3 , p 3 /resection (Figure 3; 95% CI 0.37-1.3 cm 3 , p 3 /resection (Figure 4; 95% CI 2.4-4.9 cm 3 , p Conclusions A patient-specific 3D printing based simulation module shows promise as a tool to augment and improve cardiothoracic resident training in septal myectomy. The residents were quickly able to perform resections on par with the attending. Residents rated the simulator favorably. Each resident benefited by xxxxx the anatomy of 5 separate patients.

Heart failure (HF) presents with a wide spectrum of disease severity and with a broad risk of associated morbidity and mortality. Identification of individuals at high risk for HF death is important for assessment of candidacy for heart transplantation and mechanical circulatory assistance and, more broadly, for guiding pharmaceutical, surgical, or palliative interventions. In this article, we review and compare several of the HF risk prediction tools currently available, highlighting their clinical utilities and potential shortcomings. Risk prediction tools must be carefully selected, recognizing that their accuracy is likely to be greatest when used in patients most similar to those from whom the tool was developed. As HF is a dynamic condition, serial risk assessment at regular intervals and as patient clinical status changes is warranted, although clinical evidence to support this practice is limited.

Background: Current guidelines do not support routine use of implantable cardioverter-defibrillators (ICDs) in patients (pts) with end-stage heart failure (HF), unless these pts are awaiting advanced HF therapies such as left ventricular assist devices (LVADs) or a heart transplantation (HT). Whether ICDs improve survival in end-stage HF pts awaiting HT has not been previously examined in a large, multicenter cohort. Hypothesis: Presence of ICDs at time of listing for HT is associated with lower waitlist mortality. Methods: The United Network for Organ Sharing registry was used to identify adults (≥18 years) listed for HT between January 4, 1999 & September 30, 2014. Pts with congenital heart disease, total artificial heart, restrictive cardiomyopathy, prior HT, or missing covariates were excluded. Cox regression analysis was used to assess the impact of an ICD at the time of listing on waitlist mortality. Results: The analysis included 36,397 pts (mean age 53±12; 77% males) listed for HT. The prevalence of ICDs at listing has steadily increased over time before reaching a plateau in 2006 (27% in 1999, and range 76-82% between 2006-2014). In the unadjusted model, ICD use was associated with a 36% reduction in waitlist mortality (HR 0.64, 95% CI 0.60-0.68, p Conclusion: ICDs are increasingly prevalent in pts listed for HT; however many pts are still listed for HT without these devices. The presence of an ICD at the time of listing is associated with lower mortality on the waitlist. Although the magnitude of ICD efficacy diminishes slightly, its benefit continues to remain significant even after adjustment for listing era and LVAD use. Further analyses are required to identify specific sub-groups of pts where ICD use is most beneficial and appropriate.

Background Heart transplant remains the definitive therapy for advanced heart failure patients but is limited by organ availability. We identified a large number of donor hearts from our organ procurement organization (OPO) being exported to other regions. Methods We engaged a multidisciplinary team including transplant surgeons, cardiologists, and our OPO colleagues to identify opportunities to improve our center-specific organ utilization rate. We performed a retrospective analysis of donor offers before and after institution of a novel review process. Results Each donor offer made to our program was reviewed on a monthly basis from July 2013 to June 2014 and compared with the previous year. This review process resulted in a transplant utilization rate of 28% for period 1 versus 49% for period 2 ( P = .007). Limiting the analysis to offers from our local OPO changed our utilization rate from 46% to 75% ( P = .02). Transplant volume increased from 22 to 35 between the 2 study periods. Thirty-day and 1-year mortality were unchanged over the 2 periods. A total of 58 hearts were refused by our center and transplanted at other centers. During period 1, the 30-day and 1-year survival rates for recipients of those organs were 98% and 90%, respectively, comparable with our historical survival data. Conclusions The simple process of systematically reviewing donor turndown events as a group tended to reduce variability, increase confidence in expanded criteria for donors, and resulted in improved donor organ utilization and transplant volumes.

Background Patients with heart failure are at increased risk of both sudden death and pump failure death. Strategies to better identify those who have greatest net benefit from implantable cardioverter-defibrillator (ICD) implantation could reduce morbidity and maximize cost-effectiveness of ICDs. Objective We aimed to identify baseline variables in patients with cardiomyopathy that are independently associated with a disproportionate fraction of mortality risk attributable to sudden death vs nonsudden death. Methods We used data from 9885 patients with heart failure without ICDs, of whom 2552 died during an average follow-up of 2.3 years. Using commonly available baseline clinical and demographic variables, we developed a multivariate regression model to identify variables associated with a disproportionate risk of sudden death. Results We confirmed that lower ejection fraction and better functional class were associated with a greater proportion of mortality due to sudden death. Younger age, male sex, and higher body mass index were independently associated with a greater proportional risk of sudden death, while diabetes mellitus, hyper/hypotension, higher creatinine level, and hyponatremia were associated with a disproportionately lower risk of sudden death. The use of several heart failure medications, left ventricular end-diastolic dimension, or NT-pro brain natriuretic peptide concentrations were not associated with a disproportionate risk of sudden death. Conclusion Several easily obtained baseline demographic and clinical variables, beyond ejection fraction and New York Heart Association functional class, are independently associated with a disproportionately increased risk of sudden death. Further investigation is needed to assess whether this novel predictive method can be used to target the use of lifesaving therapies to populations who will derive greatest mortality benefit .

Objective This study investigates the relationship of periportal fibrosis on postoperative outcomes after ventricular assist device (VAD) implantation. Methods Between July 2005 and August 2014, a total of 233 patients were implanted with continuous flow VADs. Liver biopsy was performed on 16 patients with concern for liver disease. Survival was evaluated using the Kaplan-Meier method. The effect of fibrosis on length of stay (LOS) in the intensive care unit was modeled using Poisson regression. Adjustments were made for age, profile from the Interagency Registry for Mechanically Assisted Circulatory Support, biopsy, and model for end-stage liver disease score. Results Fourteen of the 16 patients who underwent biopsy had periportal fibrosis without cirrhosis. One-year survival for the groups with and without biopsy-proven fibrosis was 93% ± 7% and 86% ± 2% ( P = .97), respectively. The intensive care unit LOS was not different for those with (median, 7 days; interquartile range: 3-14 days) versus without fibrosis (median, 6 days; interquartile range 4-10 days; P = .65). Fibrosis ( P = .42), age (0.95), model for end-stage liver disease excluding internal normalized ratio–XI score ( P = .64), performance of a biopsy ( P = .28), and Interagency Registry for Mechanically Assisted Circulatory Support class ( P = .70) were not associated with intensive care unit LOS. Risk was increased of gastrointestinal bleeding (14% vs 4%; P = .026) in the first year among patients with fibrosis. Conclusions The presence of periportal fibrosis did not affect survival or outcomes in patients undergoing VAD implantation. These findings suggest that carefully selected patients with advanced heart failure and hepatic fibrosis without cirrhosis may achieve acceptable outcomes with VAD implantation.

Objectives To investigate the effect of pulmonary function testing on outcomes after continuous flow left ventricular assist device implantation. Methods A total of 263 and 239 patients, respectively, had tests of forced expiratory volume in 1 second and diffusing capacity of the lungs for carbon monoxide preoperatively for left ventricular assist device implantations between July 2005 and September 2015. Kaplan-Meier analysis and multivariable Cox regressions were performed to evaluate mortality. Patients were analyzed in a single cohort and across 5 groups. Postoperative intensive care unit and hospital lengths of stay were evaluated with negative binomial regressions. Results There is no association of forced expiratory volume in 1 second and diffusing capacity of the lungs for carbon monoxide with survival and no difference in mortality at 1 and 3 years between the groups (log rank P = .841 and .713, respectively). Greater values in either parameter were associated with decreased hospital lengths of stay. Only diffusing capacity of the lungs for carbon monoxide was associated with increased intensive care unit length of stay in the group analysis ( P = .001). Ventilator times, postoperative pneumonia, reintubation, and tracheostomy rates were similar across the groups. Conclusions Forced expiratory volume in 1 second and diffusing capacity of the lungs for carbon monoxide are not associated with operative or long-term mortality in patients undergoing continuous flow left ventricular assist device implantation. These findings suggest that these abnormal pulmonary function tests alone should not preclude mechanical circulatory support candidacy.

The authors conclude that survival from sudden cardiacdeath is increased among those randomized to an implantablecardioverter-defibrillator (ICD). In addition, the probability of sur-vival from heart failure death was not reduced among those receivingICD therapy.Another approach to measuring the effect of ICD therapy on thetype of death is to assess the odds of the mode of death given that adeathoccurred.WeusedthedatasuppliedintheSCD-HeFTauthors’table and multinomial logistic regression to assess the odds ofselected types of cardiac death relative to the odds of heart failuredeath. When comparing the odds of tachyarrythmic death to heartfailure death, the odds of a tachyarrythmic death were higher in theplacebo [odds ratio 2.8, 95% confidence interval 1.7–4.6] andamiodarone (odds ratio 2.2, 95% confidence interval 1.3–3.6) groupscompared with the ICD group. The modeled probability of a cardiacdeath being a heart failure death over the course of the study was59% in the ICD group versus 41% in the amiodarone group and 40%in the placebo groups. The probability of tachyarrythmic deaths was30% for the ICD group, 46% for the amiodarone group, and 57% forthe placebo group. From the standpoint of the type of death, giventhat a death occurred, we can conclude that heart failure deaths aremore frequent in the ICD group.From the SCD-HeFT authors’ analysis, we may conclude that ICDtherapy does not alter survival from heart failure deaths, in contrastto observations that ICD placement may reduce overall mortalitywhile increasing heart failure deaths. ICDs certainly do not hastendeath from heart failure, but ICDs will allow more patients to beexposed to the baseline risk of heart failure death. This effect is wellvisualized in the mode of death curves reported in the Defibrillatorin Acute Myocardial Infarction Trial (DINAMIT), which shows thatwhen arrhythmic deaths are censored, the likelihood of nonarrhyth-mic deaths in the ICD arm increases relative to the control arm.

Right ventricular (RV) dysfunction in the setting of cardiomyopathy, ischemia, and pulmonary hypertension is associated with high morbidity and mortality, but therapeutic clinical trials examining RV failure as a primary outcome are lacking. This review focuses on the ontologic, morphologic, and microscopic differences between the right and left ventricles. It also discusses the rationale and potential risks associated with the extrapolation of medical therapies used in left ventricular failure and pulmonary arterial hypertension management to the treatment of RV failure. Finally, it introduces the reader to new echocardiographic techniques that may be used to diagnose clinical and subclinical RV systolic and diastolic dysfunction. Given the anticipated rise in the prevalence of RV dysfunction, more studies are needed to gain a better understanding of RV cellular and subcellular function and its response to pathologic stressors and disease so that therapeutic targets can be devised to improve RV failure morbidity and mortality.

Survival after cardiac transplantation continues to improve, and many transplant recipients are able to re-enter the workforce. The 2010 ISHLT report identifies the median survival among heart transplant recipients as 13 years for those patients living beyond the first year of transplant and 10