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Advanced heart failure patients demonstrate significant improvements in survival and quality of life when supported by the HeartWare Ventricular Assist System (HVAD). Patients who are not considered for cardiac transplantation due to comorbid obesity may remain candidates for left ventricular assist

Background Thrombin activity increases in patients treated with coronary thrombolysis for acute myocardial infarction, but the mechanisms are not well defined. We have shown that thrombin activity increases in plasma and whole blood incubated with plasminogen activators and appears to be plasmin mediated and dependent on activity of the factor VIIIa/IXa complex. Methods and Results In the present study, increases in thrombin activity induced by incubation of recalcified citrated plasma with 0.16 to 0.5 μmol/L plasmin at 37°C were markedly attenuated in recalcified citrated plasma deficient in factors XI or XII, prekallikrein, or high molecular weight kininogen, as well as in plasma incubated with plasmin in the presence of 3.5 μmol/L corn trypsin inhibitor, a specific factor XIIa inhibitor. Increases in thrombin activity also occurred in nonanticoagulated whole blood incubated with pharmacological concentrations of plasminogen activators and were markedly attenuated in the presence of corn trypsin inhibitor. Plasmin-mediated (0.25 μmol/L) activation of purified factor XII occurred in 0.05 mol/L Tris-HCl and 0.012 mol/L NaCl (pH 7.8) at 37°C, resulting in equimolar quantities of two fragments that corresponded to cleavage of factor XII at Arg 353 -Val 354 , the site involved in kallikrein-mediated activation of factor XII, and cleavage at Lys 346 -Ser 347 , an apparently novel site of plasmin-mediated hydrolysis of factor XII. Contact activation was also demonstrated in plasma samples from patients after treatment with fibrinolytic agents for myocardial infarction, by demonstrating cleavage of high molecular weight kininogen from its one-chain to its two-chain form by ligand blotting with 125 I-prekallikrein. Conclusions Plasmin-mediated activation of the contact system of coagulation appears to account, at least in part, for increases in procoagulant activity in patients treated with fibrinolytic agents. It may also explain hypotension, by release of bradykinin from high molecular weight kininogen, and complement activation, by activated factor XII, that has been demonstrated in these patients.

Nitric oxide (NO), the end product of the inducible form of NO synthase (iNOS), is an important mediator of a variety of inflammatory diseases. Therefore, a radiolabeled iNOS radiopharmaceutical for assessing iNOS protein concentration as a marker for its activity would be of value to the study and treatment of NO-related diseases. We recently synthesized an (18)F-radiolabeled analog of the reversible NOS inhibitor, 2-amino-4-methylpyridine ((18)F-NOS), and confirmed its utility in a murine model of lung inflammation. To determine its potential for use in humans, we measured (18)F-NOS myocardial activity in patients after orthotopic heart transplantation (OHT) and correlated it with pathologic allograft rejection, tissue iNOS levels, and calculated human radiation dosimetry.Two groups were studied-a kinetic analysis group and a dosimetry group. In the kinetic analysis group, 10 OHT patients underwent dynamic myocardial (18)F-NOS PET/CT, followed by endomyocardial biopsy. Myocardial (18)F-NOS PET was assessed using volume of distribution; standardized uptake values at 10 min; area under the myocardial moment curve (AUMC); and mean resident time at 5, 10, and 30 min after tracer injection. Tissue iNOS levels were measured by immunohistochemistry. In the dosimetry group, the biodistribution and radiation dosimetry were calculated using whole-body PET/CT in 4 healthy volunteers and 12 OHT patients. The combined time-activity curves were used for residence time calculation, and organ doses were calculated with OLINDA.Both AUMC at 10 min (P0.05) and tissue iNOS (P0.0001) were higher in patients exhibiting rejection than in those without rejection. Moreover, the (18)F-NOS AUMC at 10 min correlated positively with tissue iNOS at 10 min (R(2) = 0.42, P0.05). (18)F-NOS activity was cleared by the hepatobiliary system. The critical organ was the bladder wall, with a dose of 95.3 μGy/MBq, and an effective dose of 15.9 μSv/MBq was calculated.Myocardial (18)F-NOS activity is increased in organ rejection (a condition associated with increased iNOS levels) and correlates with tissue iNOS measurements with acceptable radiation exposure. Although further modifications to improve the performance of (18)F-NOS are needed, these data show the feasibility of PET of iNOS in the heart and other tissues.

Background Left ventricular assist devices (LVADs) have revolutionized the management of end-stage heart failure (ESHF). However, unexpectedly high rates of GI bleeding (GIB) have been described, and etiology and outcome remain unclear. Objective To determine the prevalence, etiology, and outcome of GIB in LVAD recipients. Design Retrospective case series. Setting Tertiary care academic university hospital. Patients 154 ESHF patients (55.4 years, 122 men/32 women) with LVADs implanted over a 10-year period. Main outcome measurements Overt or occult GIB prompting endoscopic evaluation ≥7 days after LVAD implantation. Results Over a mean of 0.9 ± 0.1 years of follow-up, 29 patients (19%) experienced 44 GIB episodes. Patients with GIB were older and received anticoagulation therapy before devices were implanted ( P ≤ .02 for each). GIB was overt (n = 31) rather than occult (n = 13), and most patients presented with melena (n = 22, 50%); hemodynamic instability was observed in 13.6%. Each bleeding episode required 2.1 ± 0.1 diagnostic or therapeutic procedures, and a source was localized in 71%. Upper endoscopy provided the highest diagnostic yield; peptic bleeding (n = 14) and vascular malformations (n = 8) dominated the findings. Endoscopy was safe and well tolerated. Overall mortality was 35%, none directly from GIB. Limitation Retrospective design. Conclusions Rates of GIB with LVADs are higher than that seen in other patient populations, including those receiving anticoagulation and antiplatelet therapy. GIB episodes are mostly overt and predominantly from the upper GI tract. Endoscopy is safe in the LVAD population.

Background— The HeartMate II (HMII) destination therapy (DT) trial demonstrated significant improvements in outcomes in continuous-flow left ventricular assist devices compared with patients implanted with the pulsatile-flow HeartMate XVE. The primary hypothesis of the current study is that trial patients enrolled after the initial data cohort would have better clinical outcomes. Methods and Results— Two hundred eighty-one patients who underwent HMII for DT from May 2007 to March 2009 (Mid Trial [MT] group) were compared with the initial 133 HMII patients from March 2005 to May 2007 (Early Trial [ET] group). Patient entry criteria were the same during the 2 time periods. Survival, adverse events, and quality of life were compared between the 2 groups. Baseline characteristics were similar between the groups. Compared with the ET group, patients in the MT group had reduced adverse event rates for bleeding requiring transfusions (1.66 versus 1.13 events per patient-year, P P =0.025), device-related infections (0.47 versus 0.27, P P =0.01). Other event rates were similar between groups including ischemic stroke (0.06 versus 0.05 events per patient-year, P =0.57). Survival at 1 year in the MT group was 73% versus 68% in the ET group ( P =0.21). Additionally, there was a significant reduction in deaths caused by hemorrhagic stroke ( P =0.01). Quality of life improvements were significant in both the groups ( P Conclusions— The benefit of DT therapy with the HMII is confirmed in subsequent trial patients, with improved adverse event rates and a strong trend for improvements in survival. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00121485.

Background : Left ventricular assist devices have become increasingly common for the treatment of acute and chronic heart failure. It is unclear whether these devices can handle the increased stresses caused by pregnancy. Case : An 18-year-old woman received a left ventricular assist device after peripartum cardiomyopathy. The patient was not adherent to prescribed medical regimens until she returned 11 months later, at 33 weeks of gestation. She underwent anticoagulation and inpatient surveillance until a cesarean delivery at approximately 34 weeks (based on ultrasound estimates). Conclusion : Left ventricular assist devices are allowing patients to live with minimal symptoms of heart failure and return to a good quality of life.

BACKGROUND: Quantification of donor-associated risk in a specific heart transplant recipient is often difficult. Our aim was to identify donor characteristics that affect survival in the contemporary era. METHODS: Between 1990 and 2006, 7,322 patients from 32 centers in the Cardiac Transplant Research Database underwent heart transplantation. Multivariable logistic regression analysis was used to identify donor-associated risk predictors and important interactions between these donor characteristics. Recipient survival was examined using parametric regression analysis in the hazard function domain. RESULTS: Donor characteristics associated with post-transplant death included donor age, donor requirement for vasoactive therapy, positive donor cytomegalovirus serology, longer graft ischemic time, and lower donor body weight. Several interactions between individual donor characteristics affected survival. In male donors, history of hypertension and diabetes mellitus were risk factors for death (p = 0.006, p = 0.04, respectively), but not in female donors (p = 0.5, p = 0.8, respectively). There was a significant interaction between donor age and recipient-donor weight difference. If the donor was of younger age, increasing recipient-donor weight difference did not result in increased death. With increasing donor age, weight difference did result in compromised survival (p < 0.0003). Donor and recipient gender further modified the degree of risk: risk was higher in female donors and when recipients were male (p < 0.0003). CONCLUSIONS: This multi-institutional analysis identified important interactions between donor characteristics that affect post-transplant survival that explain some of the discrepancies in the results of previous studies. The results are likely to aid in efficient organ allocation.

A 30-year-old man presenting with 2 months of increasing cough and worsening dyspnea with minimal exertion was diagnosed with nonischemic dilated cardiomyopathy. An initial ECG revealed sinus tachycardia and left atrial enlargement. Despite maximal medical management, his symptoms and cardiac function did not improve. Orthotopic heart transplantation was performed using biatrial anastomosis from a 27-year-old donor. In this procedure, the donor atria are sutured to intact remnants of the native right and left atria, allowing for minimal interruption of blood flow from both vena cavae and all the recipient’s pulmonary veins while requiring fewer anastomotic connections. The recipient’s native right and left atrial remnants are physically and electrically intact and are sutured into and electrically isolated from the donor atria. A postoperative ECG was performed (Figure 1), revealing …

Introduction: Poor health literacy is associated with worse outcomes in patients with heart failure; however, the role of health literacy in predicting outcomes in patients implanted with left ventricular assist devices (LVADs) has not yet been studied. We hypothesized that health literacy would independently influence clinical outcomes in patients implanted with continuous-flow LVADs (CF-LVADs). Hypothesis: Poor health literacy is associated with worse outcomes in patients with end-stage heart failure implanted with CF-LVADs. Methods: We performed a prospective, single center, cohort study of adult patients with implanted CFLVADs. We identified 118 patients implanted with a Heart Mate II (n5101) or an HVAD (n517) implanted between 8/2005 and 9/2013. Health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine (REALM), with adequate health literacy defined as a score $ 61 (REALM IV) and poor literacy defined as a score ! 61 (REALM I-III). The primary outcome was combined all-cause death, stroke, gastrointestinal bleeding (GIB), LVAD-related infection, or hemolysis/pump thrombosis; components of the combined primary outcome were analyzed separately as secondary outcomes. Results: The majority of patients were implanted with Heart Mate II LVADs and had an INTERMACS profile of 2. The poor health literacy group (n538) had significantly more patients with a history of smoking (76% vs. 49%, p 5 0.005), a destination therapy strategy (53% vs. 30%, p 5 0.05), and a history of GIB (58% vs. 26%, p 5 0.003). There were no significant differences between cohorts with respect to age, date of implant, BMI, race, sex, etiology of cardiomyopathy, or history of diabetes. During a follow-up period of 88.8 patient-years there were 89 events: 32 in the poor health literacy group and 57 in the adequate health literacy group (84% vs. 71%, HR 1.56, CI 1.01-2.42, p 5 0.0466), see figure. This was driven primarily by GIB events of which there were 22 in both groups (58% vs. 28%, HR 2.57, CI 1.56-5.81). There were no significant differences in individual secondary outcomes of all-cause death

Severe neurologic complications after cardiac transplantation are devastating outcomes of this life-saving procedure. Incidence, risk factors, and morbidity of neurologic events in the modern era of cardiac transplantation are yet to be defined.Between 1996 and 2005, 200 patients (64% men; mean age, 49 +/- 12 years) underwent heart transplantation at our institution. Overall, 46 patients (23%) showed a wide spectra of early neurologic complications.Cause of ischemic complications was stroke in 11 patients (7 had concomitant epileptic seizures) and transient ischemic attack (TIA) in 7. Encephalopathy (n = 10), epileptic seizures unrelated to focal cerebral lesions (n = 7), severe headache (n = 6), cerebral infection (n = 3), and peripheral nervous system injuries (n = 2) completed the spectra of adverse neurologic outcomes. Multivariate analysis identified advanced age (p = 0.03), preoperative left ventricular assist device support (p = 0.02), preoperative intraaortic balloon pump support (p0.001), prolonged cardiopulmonary bypass time (p0.001), and postoperative hepatic failure (p = 0.04) as independent predictors of early neurologic complications. Postoperative morbidities associated with neurologic complications included longer ventilation time (p0.001), longer stay in the intensive care unit (p0.001), and higher incidence of pneumonia (p0.001) and sepsis (p = 0.01) compared with patients without neurologic events. There was a trend toward higher in-hospital mortality (15% versus 6%, p = 0.07), but there was no difference in long-term survival (65% versus 78%, p = 0.15).Despite rigorous pretransplantation screening, neurologic complications were common after cardiac transplantation. Most frequently, these complications were not the actual cause of death, but they significantly contributed to increased morbidity. Preoperative mechanical circulatory support requirement was the strongest predictor for adverse neurologic outcome.

Background Heart failure is a common and important cause of morbidity and mortality. Disease management offers promise in reducing the need for hospitalization and improving quality of life for heart failure patients, but experimental data on the efficacy of such programs are limited. Methods and Results A total of 151 patients hospitalized with heart failure were randomized to usual care or scheduled telephone calls by specially trained nurses promoting self-management and guideline-based therapy as prescribed by primary physicians. Nurses also screened patients for heart failure exacerbations, which they managed with supplemental diuretics or by contacting the primary physician for instructions. Outcomes included time to hospital encounter, mortality, number and cost of hospitalizations, functional status, and satisfaction with care. Intervention patients had a longer time to encounter (hazard ratio [HR]=0.67; 95% confidence interval [CI] 0.47–0.96; P =.029), hospital readmission (HR=0.67; CI 0.46–0.99; P =.045), and heart failure–specific readmission (HR=0.62; CI 0.38–1.03; P =.063). The number of admissions, hospital days, and hospital costs were significantly lower during the first 6 months after intervention but not at 1 year. The intervention had little effect on functional status, mortality, and satisfaction with care. Conclusion A nurse-administered, telephone-based disease management program delayed subsequent health care encounters, but had minimal impact on other outcomes.

Objectives Our aim was to determine the effect of β-adrenergic blockade on the prognostic value of peak oxygen consumption testing in patients with heart failure. Background Peak oxygen consumption has been shown to be a useful prognostic tool in patients with heart failure. However, studies demonstrating the utility of peak oxygen consumption were conducted before β-blocker therapy became widespread. Thus, our objective was to determine the effect of β-blockers on the prognostic value of peak oxygen consumption in patients with heart failure. Methods Actuarial, anthropomorphic, hemodynamic and exercise ventilatory data were collected from 369 patients with heart failure. Death and orthotopic heart transplants were the events tracked. Patients were divided into those taking β-blockers and those not taking them. Event-free survival days were calculated. Results One hundred ninety-nine patients on β-blockers and 170 not on β-blockers were studied. There were 40 orthotopic heart transplants and 82 deaths during follow-up. Peak oxygen consumption (milliliters per kilogram per minute) trended toward being an independent predictor of event-free survival (p = 0.055). In patients on and not on β-blockers, a peak oxygen consumption of >14 ml/kg·min was associated with a 1-year event rate of approximately half of that associated with a peak oxygen consumption ≤14 ml/kg·min. However, for every level of peak oxygen consumption, the event rate was lower in the group taking β-blockers. Conclusions β-blocker status does not change the predictive power of peak oxygen consumption in patients with heart failure, but β-blocker status is important to consider when using peak oxygen consumption to predict event-free survival in patients with heart failure.

Background: Renal dysfunction (RD) is common in heart failure (HF) and is an important predictor of mortality in patients undergoing left ventricular assist device (LVAD) placement. Evaluation of renal function in LVAD candidates is generally accomplished via serum creatinine (Cr) based estimates. This is problematic since Cr level is influenced not only by renal function but also the amount of Cr produced by skeletal muscle. Since cardiac cachexia is common in HF, it is unclear to what degree reduced muscle mass and Cr production will affect estimates of glomerular filtration rate (GFR). Hypothesis: We hypothesized that, in patients referred for LVAD placement, Cr production would be significantly lower than predicted resulting in a significant underestimation of the burden of RD in these patients. Methods: Consecutive adult patients who underwent LVAD placement with 24-hour Cr collections available were studied (n562). Cr production was determined using the 24 hour cumulative Cr excretion; measured Cr clearance was calculated using the standard clearance equation. Renal function was also estimated from the serum Cr using the Cockgroft-Gault (CG) equation and the CKD-EPI equation. All parameters of renal function were indexed to a BSA of 1.73 m. Results: The mean age of the cohort was 54.5 6 14.6 years, 74.3% (n546) were male and 51.6% (n532) were African American. Despite an elevated BMI of 29.9 6 8.06 kg/m, the mean 24 hour Cr excretion was only 12796 474 mg (compared to a predicted value in this cohort of 19386 615 mg, p!0.001) confirming marked sarcopenia. Overall, less than 30% of patients’ Cr excretion was in the normal range after accounting for age and BSA. Significant preLVAD RD was present with a mean measured Cr clearance of 49.5 6 22.3 ml/min/ 1.732. Both the CG and the CKD-EPI equation overestimated GFR with a median error of 22.3% (10.9-34.0%) and 19.8 % (10.4-31.2%) respectively. This translated into 25.8% of the patients being misclassified using CKD-EPI and 35.5% being misclassified by CG into a greater CKD stage than indicated by measured Cr clearance. Conclusions: HF patients undergoing LVAD placement exhibit decreased Cr production likely as a result of significant cardiac cachexia. Since GFR estimation equations assume normal Cr production, this led to significant overestimation of GFR and misclassification of patients into higher CKD stages. Further research is necessary to determine if non-creatinine based metrics of renal function could improve preLVAD evaluation of RD.

Clinical Summary Between January 2000 and September 2004, 15 patients received destination LVAD therapy in our institution. Nine patients had received the Novacor device as part of the INTrEPID (Investigation of Non-Transplant-Eligible Patients who are Inotrope Dependent) trial, and 6 had received the HeartMate XVE device (Thoratec Corporation) after US Food and Drug Administration approval was granted for destination therapy. From this group, 6 patients were reevaluated and listed for transplantation. The mean age was 52 years (range, 31-66 years). The cause of the underlying cardiomyopathy was ischemic in 4 patients, idiopathic in 1 patient, and adriamycin-induced heart failure in 1 patient. Contraindications for cardiac transplantation before LVAD destination therapy were irreversible severe pulmonary hypertension in 5 patients, 2 of whom also had concomitant renal insufficiency and 1 of whom had a recent history of treated endometrial cancer (Table 1). After LVAD implantations, significant reduction in pulmonary arterial pressure, pulmonary vascular resistance, and renal function was seen in these patients (Table 2). Heart transplantation was initially contraindicated in another patient because of psychosocial history and poor compliance. The mean duration of LVAD support until listing among the 6 patients was 243 days (range, 88-684 days). Four patients have undergone transplantation and are alive at a mean duration of 33 months (range, 8-55 months; Table 1). One patient is still on the waiting list, and 1 died from a hemorrhagic cerebrovascular accident before undergoing transplantation. In the one patient with cancer, there has been no evidence of recurrence. None of the patients who underwent transplantation with previous pulmonary hypertension had significant perioperative right ventricular dysfunction. The remaining 9 patients with LVAD destination therapy were not offered heart transplantation because of either the presence of ongoing contraindications to heart transplantation or perioperative death after LVAD implantation. The contraindications to heart transplantation in these 9 patients were significant comorbidity in 3 patients, advanced age in combination with significant comorbidity in 3 patients, and malignancy in 2 patients. At a mean follow-up of 200 days (range, 1-1095 days), 5 patients were deceased, whereas the remaining patients were still alive. The causes of death in the 5 patients were multiorgan failure in 3 patients, traumatic hemorrhagic cerebrovascular accident after a motor vehicle accident in 1 patient, and intraoperative death in 1 patient.

Incidence of Sedation Related Adverse Events (Srae) During Endoscopy in Patients Supported by Continuous Flow Left Ventricular Assist Devices (LVAD) Vladimir M. Kushnir, Laura M. De Mondesert*, Susan Joseph, Gregory A. Ewald, Scott Silvestry, Steven A. Edmundowicz Gastroenterology, Washington University School of Medicine, St. Louis, MO; Cardiology, Washington University School of Medicine, St Louis, MO; Cardiothoracic Surgery, Washington University School of Medicine, St Louis, MO Background: Continuous flow LVADs have revolutionized management of advanced heart failure in the past decade. Gastrointestinal complications requiring diagnostic and therapeutic endoscopy are common during long term LVAD support. Patients with advanced heart failure are considered high risk for SRAE during endoscopy. In patients supported by LVADs the risk is compounded by lack of pulsatile blood flow; which makes vital sign monitoring challenging. Aim: Define the incidence of SRAE during endoscopy in the LVAD population. Methods: Consecutive patients supported by the HeartMate II LVAD undergoing endoscopy with conscious sedation (CS) or propofol based sedation under monitored anesthesia care (MAC) at a tertiary care center between 2005-12 were retrospectively identified. Clinical records were interrogated and the incidence of SRAE was recorded. SRAE were defined as: hypoxemia (SaO2 90%), respiratory failure requiring intubation, new onset arrhythmia, hypotension (mean arterial pressure 60mmHg), low LVAD flow ( 4 L/min) and premature procedure termination. Logistic regression analysis was used to identify independent risk factors for SRAE. Results: 74 patients underwent 190 endoscopic procedures [median 2 per patient (range 1-10)] while supported by LVAD. Procedures included: 61 upper endoscopies, 71 colonoscopies, 24 small bowel enteroscopies (SBE), 34 upper endoscopy colonoscopy (during same sedation). 110 (57.8%) procedure were performed under MAC. There were no significant differences in baseline patient or procedure characteristics between MAC & CS groups (table 1). SRAE occurred more frequently with MAC [53/110] then CS [24/80], p 0.01 (Table 2). One procedure performed under CS was terminated prematurely due to a 10 second episode of ventricular tachycardia, which resolved spontaneously. The reminders of SRAE were successfully treated without procedure interruption. There were no episodes of respiratory failure requiring tracheal intubation. All episodes of hypotension were successfully treated with fluid (n 40, 21.1%) and/or neosynephrine bolus (n 39, 20.1%); none of the patients required continuous vasopressor infusion. In a linear regression model containing demographics and procedural factors sedation related AE were significantly associated with the use of MAC [OR 2.0(95%CI 1.13.9), p 0.04)] and performing SBE [OR 5.6(95%CI 1.9-16.9), p 0.002). Conclusions: SRAE occur in 40% of LVAD supported patients during endoscopy; however the vast majority of SRAE are transient and can be treated successfully without procedure interruption. Hypotension is the most frequent SRAE and the need for inter-procedural vasopressor administration should be anticipated, particularly when patients are sedated with MAC. Independent predictors of SRAE were the use of MAC and performing SBE.

Purpose Ventricular unloading with continuous flow LVADs (CFLVAD) has been correlated with reduction of pulmonary artery pressures (PAP) during support. The impact of severity of mitral regurgitation on the observed reduction in PAPs has not been defined. The necessity of additional surgical interventions on the mitral valve in patients with moderate or severe MR during LVAD implantation is controversial. Further, the magnitude of improvement in severity of MR in CFLVAD is undefined. Methods and Materials From January 2009 to January 2012, 245 patients underwent placement of CFLVAD (HeartMate2, HeartWare) at our institution. We compared preoperative right heart hemodynamics and echocardiograms to long term post support echocardiography with complete follow-up in 200 patients (82%). Results Average time from implant to long term study was 262±317 days. After CFLVAD placement, 94.5 % of patients had improvement or no change in MR and 5.5% of patient had worse MR. Improvement of ≥ to one grade was seen in 76.5 % (153/200) patients. Furthermore, 61.5 % (123/200) of patients had ≥2 grade improvement and 60% of patients had no MR or a 3 grade improvement (p Conclusions Heart failure patients with moderate to severe MR have significant reductions in MR after CFLVAD. CFLVADs significantly unload the pulmonary vasculature, regardless of the degree of MR. Mitral valve procedures may not be necessary in addition to LVAD implantation to achieve long term pulmonary vascular decompression in the patients with moderate to severe MR. Pre-operative MR Grade Pre-Operative MR (patients) Severe Moderate Mild Trivial/None Pre-op PASP Long Term PASP Severe (65) 9% 15% 40% 35% 58± 14 33± 10 Moderate (60) 5% 18% 33% 45% 59 ±12 31± 11 Mild (58) 0% 9% 33% 59% 57± 15 32± 12 Trivial/None (17) 0% 0% 18% 82% 52 ± 12 30 ± 10 Improvement of MR from baseline in all groups (p

Implantable left ventricular assist device (LVAD) drive-line exit site infection, an expected consequence of currently available device use, continues to be a significant limiting factor in long-term support. We theorize that the mechanism behind the establishment of the most chronic exit site infections involves a shearing torsion injury that disrupts the tissue adherence interface with the drive-line. The resulting neo-epithelialized drainage tract prevents permanent clearance of the infection with antibiotics alone. The proposed treatment strategy of established infections involves aggressive surgical excision of the involved exit site.

Milrinone is a phosphodiesterase type III inhibitor with positive inotropic and vasodilatory effects. A common side effect of milrinone is hypotension from the peripheral vasodilation. Although mild elevations in serum creatinine have been described previously in the setting of milrinone-induced hypotension, acute oligoanuric renal failure requiring renal replacement therapy has not yet been described. This case report is the first to document such a result and to report the successful use of peritoneal dialysis in this setting. Previous case reports documented vasopressin as an effective alternative to catecholamines in the treatment of milrinone-induced hypotension. This report documents the use of four vasopressor agents (including vasopressin) in this patient, with only vasopressin resulting in improvement in systemic vascular resistance and blood pressure. Vasopressin may be the most effective vasopressor agent in the treatment of milrinone-induced hypotension. © 2002 by the National Kidney Foundation, Inc.