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Several attempts have been made to monitor cardiac allograft rejection usingnoninvasive imaging modalities. Previous efforts to employ noninvasive imaging tofollow transplant recipients for signs of rejection have included echocardiography,1antimyosin scintigraphy,2 anti-vascular adhesion molecule scintigraphy,3 and radiolabeled lymphocyte scintigraphy.4 Each method has shown to detect clinical or experimental allograft rejection, but evidence of adequate sensitivity and specificity existsto supplant endomyocardial biopsy has been lacking.

Two-dimensional and color Doppler echocardiograms obtained in 117 patients during cardiac transplantation evaluation were reviewed. Right ventricular hypokinesia and dilation were more prevalent in patients with tricuspid regurgitation. In multivariate event-free survival analysis of 61 patients with complete clinical, echocardiographic, and cardiopulmonary exercise data, the absence of tricuspid regurgitation and New York Heart Association class were the only independent predictors of survival.

Hospitalizations for decompensated heart failure (HF) are thought to increase long-term mortality. However, previous reports focus on newly hospitalized HF patients or clinical trial populations and do not always adjust for baseline mortality risk. We hypothesized that the number of HF hospitalizations within the prior 12 months would improve overall mortality risk stratification, particularly in otherwise "low-risk" HF inpatients.We studied 2221 HF patients admitted to 14 Michigan community hospitals during 2002-2004. We estimated 1-year mortality using the multivariable (Enhanced Feedback For Effective Cardiac Treatment [EFFECT]) model and classified patients as low (EFFECT90), moderate (90-120), and high risk (120). We used logistic regression and stratified Cox proportional hazard modeling to explore the overall EFFECT model performance and the influence of HF hospitalizations within the prior 12 months on mortality risk.The EFFECT model adequately predicted and stratified for 1-year mortality (odds ratio 1.35 [95% confidence interval (CI), 1.30-1.40] per 10 points, P.001, C-statistic 0.698), with low-, moderate-, and high-risk group mortality 18%, 35%, and 58%, respectively. The number of prior HF hospitalizations only modestly improved overall discrimination (C-statistic 0.704, P=.04). However, in low-risk patients the number of prior HF hospitalizations progressively increased the hazard for 1-year mortality (none: mortality 13%; 1: mortality 20%, hazard ratio [HR] 1.50 (95% CI, 0.86-2.60), P=.15; 2 or 3: mortality 27%, HR 2.24 (95% CI, 1.39-3.60); P=.001; 4 or more: mortality 31%, HR 2.80 (95% CI, 1.70-4.63); P.001; P.001 for trend). There was no consistent relationship between prior HF hospitalizations and 1-year mortality in moderate- or high-risk HF patients.In otherwise "low-risk" HF inpatients, a history of 2 or more HF hospitalizations within the prior 12 months markedly increases 1-year mortality risk. This easily obtained information could help allocate specialized HF resources to the subset of "low-risk" patients most likely to benefit.

Purpose: Thrombosis of the Aortic Valve (AV) and Aortic Root (AR) has been described. Second generation, continuous flow LVADs (CF-LVAD) could be more prone to this problem. Unlike Pulsatile pumps which allow periodic LV filling and AV ejection (due to asynchronous operation), CF-LVADs continuously decompress the LV which reduces opportunity for ejection through the AV. We reviewed our experience with HeartMate II LVAD (HM2) to evaluate the incidence and characteristics of this clinically important problem. Methods and Materials: All HM2 patients (n 28, avg duration 290 days) underwent routine echocardiography. Thrombosis of the AV or AR was identified. Demographic and lab data from this group was then compared to patients without thrombosis. The clinical course and interventions were reviewed. Results: Five cases of thrombosis in 28 patients were identified (18%, 0.22 events/pt-yr). This contrast with our experience with HeartMate I LVADs in which this phenomenon was essentially non-existent. 3 of 5 patients (60%) were asymptomatic. One patient had a stroke with residual visual field defect. One patient presented with TIAs that completely resolved. Thrombosis was most often an early event (8, 9, 34, 36, and 403 days post-implant). Patients with thrombosis did not exhibit different pre-implant characteristics from those without thrombosis. Of interest, however, patients with thrombosis had less pulsatile flow over the 2 days prior to the event during comparable time periods after implant (average pulsatility index of 4.5 1.6 vs. 6.1 1.0, p .057). Patients with thrombosis were treated with increased anticoagulation (target INR of 2.5-3.5) following which all thrombus disappeared or stabilized. Conclusions: Aortic valve/root thrombosis in patients on Continuous Flow LVADs appears to occur with concerning frequency. The majority of these patients did not become symptomatic. Further studies are required to better define the incidence, natural course, prevention and optimum management of this clinically important problem.

Background: Serum brain natriuretic peptide (BNP) has been reported to be elevated in heart transplant recipients (HTR) with rejection. Whether elevations of BNP with rejection are due to concurrent elevation of pulmonary capillary wedge pressure (PCW) is not known. Methods: We analyzed serial BNP measurements in 40 HTR occurring beyond 60 days after transplantation, obtained during endomyocardial biopsy procedures performed as standard HTR care. To eliminate potential confounding from prior rejection episodes, we included only observations in which the previous biopsy grade was 0 or 1A (N 206 observations). Normally distributed variables are expressed as mean SD. Otherwise, variables are expressed as median (IQR). Non-parametric Kendall’s tau correlation coefficients were calculated between BNP level and biopsy grade (severity of grade 0 1A 2 1B 3A vascular rejection) and hemodynamically significant rejection (HSR, biopsy grade 2 and PCW 20 mmHg). Multivariable logistic regression was performed to test the relationship between BNP and HSR while controlling for PCW. Results: The mean systolic blood pressure was 134 19 mm Hg, PCW 13 (11, 17) mm Hg, and cardiac index 2.8 0.7 L/min/m2. Median BNP was 154 (87, 284) pg/ml . BNP for grade 0 biopsies (N 59) was 128 (70, 210) pg/ml; for grade 1A (N 24) was 151 (99, 260) pg/ml; for grade 2 (N 33) was 172 (85, 285) pg/ml; for grade 1B (N 1) was 377 pg/ml; for grade 3A (N 8) was 213 (109, 398) pg/ml; and for vascular rejection (N 4) was 1020 (763,1300) pg/ml (ANOVA p 0.001). BNP correlated significantly with both biopsy grade (R 0.192, p 0.005), HSR (R 0.301, p 0.001) and with PCW (R 0.290, p 0.001). After controlling for PCW, BNP was found to maintain a significant correlation with HSR (Beta 0.0046 0.0023, p 0.03) Conclusion: BNP levels are elevated with increasing biopsy grade in HTR and these changes are independent of PCW. The use of BNP measurement at the time of endocardial biopsy may enhance the diagnosis of HSR.

Accurately measuring the quality of cardiovascular care and attempting to determine the sources of quality deficits are difficult challenges, particularly in the outpatient setting. Clinical trials have documented the benefits of warfarin in atrial fibrillation, angiotensin-converting enzyme (ACE)

ObjectivesThis study was designed to assess effects of mitral valve annuloplasty (MVA) on mortality in patients with mitral regurgitation (MR) and left ventricular (LV) systolic dysfunction.BackgroundMitral valve annuloplasty improves hemodynamics and symptoms in these patients, but effects on long-term mortality are not well established.MethodsWe retrospectively analyzed consecutive patients with significant MR and LV systolic dysfunction on echocardiography between 1995 and 2002. Cox regression analysis, including MVA as a time-dependent covariate and propensity scoring to adjust for differing probabilities of undergoing MVA, was used to identify predictors of death, LV assist device implantation, or United Network for Organ Sharing-1 heart transplantation.ResultsOf 682 patients identified, 419 were deemed surgical candidates; 126 underwent MVA. Propensity score derivation identified age, ejection fraction, and LV dimension to be associated with undergoing MVA. End points were reached in 120 (41%) non-MVA and 62 (49%) MVA patients. Increased risk of end point was associated with coronary artery disease (hazard ratio [HR] 1.80, 95% confidence interval [CI] 1.30 to 2.49), blood urea nitrogen (HR 1.01, 95% CI 1.005 to 1.02), cancer (HR 2.77, 95% CI 1.45 to 5.30), and digoxin (HR 1.66, 95% CI 1.15 to 2.39). Reduced risk was associated with angiotensin-converting enzyme inhibitors (HR 0.65, 95% CI 0.44 to 0.95), beta-blockers (HR 0.59, 95% CI 0.42 to 0.83), mean arterial pressure (HR 0.98, 95% CI 0.97 to 0.99), and serum sodium (HR 0.93, 95% CI 0.90 to 0.96). Mitral valve annuloplasty did not predict clinical outcome.ConclusionsIn this analysis, there is no clearly demonstrable mortality benefit conferred by MVA for significant MR with severe LV dysfunction. A prospective randomized control trial is warranted for further study of mortality with MVA in this population.

Background —The use of extracorporeal life support (extracorporeal membrane oxygenation [ECMO]) as a direct bridge to heart transplant in adult patients is associated with poor survival. Similarly, the use of an implantable left ventricular assist device (LVAD) to salvage patients with cardiac arrest, severe hemodynamic instability, and multiorgan failure results in poor outcome. The use of LVAD implant in patients who present with cardiogenic shock who have not been evaluated for transplantation or who have sustained a recent myocardial infarction also raises concerns. ECMO may provide reasonable short-term support to patients with severe hemodynamic instability, permit recovery of multiorgan injury, and allow time to complete a transplant evaluation before long-term circulatory support with an implantable LVAD is instituted. After acquisition of the HeartMate LVAD (Thermo Cardiosystems, Inc), we began using ECMO as a bridge to an implantable LVAD and, subsequently, to transplantation in selected high-risk patients. Methods and Results —From October 1, 1996, through September 30, 1998, 32 adult patients who presented with refractory cardiogenic shock (cardiac index −1 · m −2 , with systolic blood pressure 3 mg/dL or oliguria; international normalized ratio >1.5 or transaminases >5 times normal or total bilirubin >3 mg/dL; and needing mechanical ventilation). Group I patients were placed on ECMO support; 7 underwent subsequent LVAD implant and 1 was bridged directly to transplant. Six patients in group I survived to transplant hospitalization discharge. The remaining 18 patients (group II) underwent LVAD implant without ECMO support; 12 survived to transplant hospitalization discharge and 2 remained alive with ongoing LVAD support and awaited transplant. One-year actuarial survival from the initiation of circulatory support was 43% in group I and 75% in group II. One-year actuarial survival from the time of LVAD implant in group I, conditional on surviving ECMO, was 71% ( P =NS compared with group II). Conclusions —In appropriately selected high-risk patients, the rate of LVAD survival after initial ECMO support was not significantly different from the survival rate after LVAD support alone. An initial period of resuscitation with ECMO is an effective strategy to salvage patients with extreme hemodynamic instability and multiorgan injury. Use of LVAD resources is improved by avoiding LVAD implant in a very-high-risk cohort of patients who do not survive ECMO.