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For patients with refractory heart failure despite optimal medical therapy, orthotopic heart transplantation (OHT) remains the treatment of choice. Since transplanted hearts have variable cardiac denervation and acute coronary syndrome often presents as a silent myocardial infarction or with atypical symptoms, the true impact of ACS on outcomes within this population needs more study. The aim of this study is to evaluate in-hospital mortality in post-transplant patients with ACS.Utilizing data from the 2002-15 Nationwide Inpatient Sample database, patients with a primary diagnosis of acute coronary syndrome among those with prior heart transplantation were included. A risk adjusted regression analysis was performed to assess if ACS post-OHT had an independent impact on the risk of in-hospital mortality. A 2:1 propensity matching was used to match ACS patients with and without OHT, respectively to assess differences in mortality.A total of 3,224,073 patients with a primary diagnosis of acute coronary syndrome were included, of which 842 (0.03%) were heart-transplant recipients. The type of ACS: NSTEMI (76.0% vs 74.5%; p = 0.32) and STEMI (24.8% vs 26.7%; p = 0.21) between heart transplant and non-heart transplant patients was similar in both groups. Following ACS, patients with heart transplant were more likely to have accompanying shock of any etiology (15.6% vs 3.8%; p 0.001) and cardiogenic shock (11.2% vs 2.6%; p 0.001) compared to those with native hearts. OHT patients also had significantly higher in-hospital mortality (14.3% vs. 3.7%; p 0.001) that remain significant following regression analysis (aOR 3.6, 95% CI 2.8-4.5; p 0.001) irrespective of the presence of cardiogenic shock compared to native hearts. This relationship remained consistent following propensity matching where patients with OHT had significantly higher in-hospital mortality (13.5% vs. 7%; p 0.001).ACS following OHT was more likely to have accompanying cardiogenic shock. ACS in the setting of prior OHT remained a strong independent predictor of higher mortality as compared to native hearts.

We present 3 cases of superior vena cava (SVC) syndrome following percutaneous right ventricular assist device (RVAD) placement. Each case underscores the importance of early recognition of SVC syndrome in patients with percutaneous RVAD insertion via the internal jugular vein and calls for heightened awareness of device-associated complications. (Level of Difficulty: Advanced.), Central Illustration

This article is an examination of the Analeptic Applications of Omega-3. The scientific development and subsequent clinical applications of Omega-3 in Healthcare continue to influence researchers all over the globe today. This article examines the research done and published by researchers and scientists. Consideration of current trends and data in scientific queries and demonstrates further aspects of the applications of Omega-3 on various health backgrounds, including. Cardiovascular Health: The study addresses the comparison of Omega-3 and Omega-6 in cardiovascular diseases. Higher intake of dietary Omega-3 helps activation, inhibition, and alteration of metabolic and signaling pathways which is associated with better cardiovascular health, while Omega-6 decreases the risk of coronary heart diseases and cardiovascular disease mortality. Immunology: Omega-3 Polyunsaturated Fatty Acids (PUFAs) have been found to show an anti-inflammatory effect in the body by downregulating the activation of various immune cells. They regulate immunological functions via eicosanoids and resolvins which are anti-inflammatory. External supplementation can reduce chronic and acute inflammation as well as reduce the chances of graft rejection. The regulatory effect is shown by modifying gene expression and/or signal transduction in human cells. They are also involved in altering the membrane composition of Fatty Acids(FA) and as a result, they affect the lipid raft structure and also membrane trafficking. Joint Health: The study shows the effects of omega-3 and other fatty acid consumption in Rheumatoid Arthritis(RA), bone marrow lesions, and knee cartilage lesions. It notes the interrelations between synovitis, plasma levels of Omega-3 and Omega-6 PUFAs in OsteoArthritis (OA) patients along with risk factors for OA, which could help consider liable treatments for improvement of OA. The study highlights the importance of the Omega-6:Omega-3 PUFA ratio and clinical and functional outcome measures which can help us in better understanding the role of PUFAs and possible treatments for people with knee osteoarthritis while showing the effect of Omega-3 fatty acids on muscle health in RA. Skin Disorders: Fish oils rich in PUFAs are reported to improve several inflammatory disorders, including rheumatoid arthritis and psoriasis. They have also been broadly reported as a potential supplement to ameliorate the severity of some skin disorders such as photoaging, skin cancer, allergy, dermatitis, cutaneous wounds, and melanogenesis. The significance of omega-3 in skin structure was proved by describing a syndrome caused by stringent fat reduction in the diet that leads to erythema with scaling, hair loss, itching, and increased water loss.

Chemotherapeutic agents have been associated with cardiotoxicity; thus, they require close monitoring. Several echocardiographic variables have been investigated as early predictors of symptomatic cardiotoxicity in patients undergoing chemotherapy.To identify if global longitudinal strain (GLS) is a better predictor of symptomatic cardiotoxicity compared to left ventricular ejection fraction (LVEF) in patients receiving chemotherapy.MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials were searched from inception through December 2020. Adults who developed symptomatic cardiotoxicity (New York Heart Association [NYHA] Class III-IV heart failure, cardiac arrest, or cardiac death) after undergoing chemotherapy with pre- and postchemotherapy echocardiographic measures of cardiac function were included. The primary focus was on the prediction of symptomatic cardiotoxicity. Estimates were reported as random effects hazard ratios (HR) with 95% confidence intervals (CI).Four studies met inclusion criteria. The most common malignancy identified in the included studies was breast cancer, and the most common chemotherapeutic agent utilized was anthracyclines. Most studies utilized the Simpson biplane method to measure echocardiographic parameters. Pooled results demonstrated no significant association between LVEF and the prediction of symptomatic cardiotoxicity (HR 1.48; 95% CI, 0.96-2.27; P = 0.07). However, 2 studies that analyzed GLS found it to be a strong predictor of symptomatic cardiotoxicity (HR 1.46; 95% CI, 1.34-1.58; P.001). There was no significant association between symptomatic cardiotoxicity and baseline left ventricular end diastolic volume, end systolic volume, or end diastolic volume index.GLS may predict symptomatic cardiotoxicity and be used to monitor patients on chemotherapy for symptomatic cardiac dysfunction. While the pooled results for baseline LVEF identified that it is not a predictor of symptomatic cardiotoxicity, this differs from the findings of the only randomized trial included in this meta-analysis. The data for baseline GLS as a predictor of symptomatic cardiotoxicity is encouraging, but definite evidence that GLS may be superior to LVEF is lacking. Prospective randomized, blinded trials are required to identify if 1 echocardiographic parameter may be superior to the other.

The SARS-CoV-2 virus, or COVID-19, is responsible for the current global pandemic and has resulted in the death of over 100,000 in the United States. Interestingly, rates of venous thromboembolism have been noted to be much higher in those infected with COVID-19. Here we report a case-series of COVID-19 patients with diverse presentations of pulmonary embolism (PE) at our institution. We also briefly describe the pathophysiology and mechanisms for pulmonary embolism in COVID-19. These cases indicate a need to maintain a high index of suspicion for PE in patients with COVID-19, as well as the need to consider occult COVID-19 infection in patients with PE in the right clinical circumstance.

Despite improved outcomes of modern continuous-flow left ventricular assist devices (CF-LVADs), device exchange is still needed for various indications. While the majority of CF-LVADs are exchanged to the same model, exchange to a different pump model is occasionally warranted. In this meta-analysis, we sought to consolidate the existing evidence to better elucidate the indications and outcomes in these cases. A comprehensive systematic search of adult patient cohorts who underwent CF-LVAD exchange to a different CF-LVAD model was performed. Study-level data from 10 studies comprising 98 patients were extracted and pooled for analysis. Mean patient age was 58 (95% CI: 48-65) and 81% were male. Indication for initial CF-LVAD was ischemic cardiomyopathy in 45% (34-57). Initial device was HeartMate II LVAD (HMII) in 93 (94.9%) and HeartWare HVAD (HW) in 5 (5.1%) patients. After mean CF-LVAD support time of 18.8 (15.2-22.4) months, exchange indications included thrombosis in 71% (43-89), infection in 21% (8-47) and device malfunction in 12% (7-21). HMII to HW exchange occurred in 53 (54.1%) patients, HMII to HeartMate III (HM3) in 32 (32.7%), and HM II to either HW or HM3 in 13 (13.2%) patients. Postoperatively, right ventricular assist device was required in 16% (8-32). Overall, 20% (8-40) of patients experienced a stroke, while HW patients had a significantly higher stroke incidence than HM3 patients (HW: 21% (8-47) vs. HM3: 5% (1-24), P < .01). Overall 30-day mortality was 10% (6-17), while HW had a significantly worse 30-day mortality than HM3 (HW: 13% (7-24) vs. HM3: 5% (1-24), P = .03). Following device exchange from a different CF-LVAD model, HM3 is associated with lower stroke and higher survival when compared to HW.

The COVID-19 pandemic underscored our healthcare system's unpreparedness to manage an unprecedented pandemic. Heart failure (HF) physicians from 14 different academic and private practice centers share their systems' challenges and innovations to care for patients with HF, heart transplantation, and patients on LVAD support during the COVID-19 pandemic. We discuss measures implemented to alleviate the fear in seeking care, ensure continued optimization of guideline directed medical therapy (GDMT), manage the heart transplant waiting list, continue essential outpatient monitoring of anticoagulation in LVAD patients and surveillance testing post-heart transplant, and prevent physician burnout. This collaborative work can build a foundation for better preparation in the face of future challenges.

Depression and anxiety in patients with heart disease and/or cancer have been shown to affect quality of life, adherence with medical management, and prognosis. We investigated the association of the diagnoses of cancer, heart disease, or both with self-reported symptoms consistent with serious mental illness (SMI). We used the K6 score to identify self-reported symptoms consistent with SMI from patients’ responses to the 2017 National Health Interview Survey. Our final cohort included 24,777 individual surveys. Of those respondents, 1509 reported cancer, 2639 reported heart disease, and 534 reported both. About 96% of patients reported a K6 score

Ultrafiltration (UF) is used for fluid removal patients with acute decompensated heart failure with reduced ejection fraction (HFrEF) refractory to diuretics. However, data on the relative merits of UF and diuretics are limited.Online databases were queried to identify clinical trials on the comparison of UF and diuretics. The major adverse cardiovascular (MACE) and its components (mortality and re-hospitalizations) were compared using the random-effects model to calculate the unadjusted odds ratio (OR) with its 95% confidence interval (CI).A total of 10 clinical trials comprising 838 patients (413 UF, 425 diuretics) were included in the analysis. At a median follow-up of 90 days, there was no significant difference in the odds of MACE (OR 0.71, 95% CI 0.47-1.07) and all-cause mortality (OR 1.08, 95% CI 0.77-1.52) between patients undergoing UF compared with those receiving diuretics therapy. The need for emergency department visits (OR 1.05, 95% CI 0.38-2.90), all-cause admissions (OR 0.97, 95% CI 0.72-1.30) and heart failure-related re-hospitalization (OR 0.47, 95% CI 0.21-1.02) was also similar between the two groups. The in-hospital risk for hypotension (OR 0.49, 0.23-1.04) and post-therapy creatinine risegt;0.3 mg/dL (OR 1.18, 95% CI 0.74-1.89) was also not significantly different between the UF and diuretics arms. A sensitivity analysis of MACE and mortality did not show any deviation from the pooled outcomes.In patients with HFrEF, UF appears to be safe but might not provide significant benefits in terms of reducing the risk of mortality or readmission rates compared with those treated with diuretics.

Introduction: Randomized controlled trials and systematic reviews evaluating the use of pulmonary artery catheters in the critically ill population have not shown beneficial effects on survival. However, many of those studies have excluded patients in cardiogenic shock. We address this evidence gap by providing a comprehensive meta-analysis to investigate the association between pulmonary artery catheter use and outcomes in patients with cardiogenic shock Hypothesis: Pulmonary artery catheter use in patients with cardiogenic shock is associated with improved mortality. Methods: We performed an extensive literature search using PubMed, MEDLINE, SCOPUS, and the Cochrane databases from January 1990 through June 2021. Data for final analysis was pooled using a random effects model. Odds ratios were used for effect size. Information on eligibility criteria, outcomes, and methodological quality was extracted by two independent reviewers. Primary study outcome was in-hospital mortality rate. Results: 16 studies were included in the analysis comprising 2,400,618 patients. Of those, 212,122 were managed with a pulmonary artery catheter (8.8%) and 2,188,496 were managed without one (91.2%). In patients with cardiogenic shock, pulmonary artery catheter use was associated with a statistically significant decrease in mortality (OR 0.82 [95% CI 0.73-0.92; p = 0.001]. The pulmonary artery catheter cohort was more likely to receive mechanical circulatory support (OR 2.16 [95% CI 1.90-2.45; p Conclusions: Pulmonary artery catheter use in patients with cardiogenic shock is associated with lower in-hospital mortality. Future studies differentiating pulmonary artery catheter use among various cardiogenic shock stages and phenotypes are needed.

Background: Early readmissions following hospital discharge for heart failure (HF) remain a major concern. Among the various strategies designed to reduce readmissions, home evaluations have been observed to have a favorable impact. We assessed the feasibility of integrating community paramedics into the outpatient management of HF patients.Methods: Selected paramedics completed an educational HF curriculum. These Mobile Integrated Health Paramedics (MIHP) performed scheduled home visits 2- and 15-days post-discharge for patients with Stage C HF (Phase I) and patients with Stage D HF (Phase II). Facilitated by a Call Center, a process was created for performing urgent MIHP house calls within 60 minutes of a medical provider's request. A HF specialist, with an on-call emergency department command physician, could order an intravenous diuretic during home visits. During each phase of the study the incidence of 30-day HF readmissions, 30-day all-cause readmissions, emergency room evaluations, unplanned office encounters, as well as any adverse events were prospectively documented.Results: Collaborative relationships between our hospital network and local EMS organizations were created. There were 82 MIHP home visits. Eight patients received urgent home evaluations within 60-minutes post-request, one requiring transport to an ED. The incidence of all-cause 30-day readmissions in 20 Stage C and 20 Stage D patients was 15% and 40%, respectively. There were no adverse events attributable to the MIHP house calls.Conclusions: It is feasible to integrate MIHPs into the outpatient management of HF. Signals of effectiveness for reducing early readmissions were observed. Obstacles to creating an effective paramedic "House Calls" program were identified. A randomized trial is required to assess the value of this care process and its impact on early readmissions in patients with Stage C and Stage D HF.

Background There is a lack of contemporary data on cardiogenic shock (CS) in‐hospital mortality trends. Methods and Results Patients with CS admitted January 1, 2004 to December 31, 2018, were identified from the US National Inpatient Sample. We reported the crude and adjusted trends of in‐hospital mortality among the overall population and selected subgroups. Among a total of 563 949 644 hospitalizations during the period from January 1, 2004, to December 30, 2018, 1 254 358 (0.2%) were attributed to CS. There has been a steady increase in hospitalizations attributed to CS from 122 per 100 000 hospitalizations in 2004 to 408 per 100 000 hospitalizations in 2018 ( P trend P trend P trend P trend Conclusions Hospitalizations attributed to CS have tripled in the period from January 2004 to December 2018. However, there has been a slow decline in CS in‐hospital mortality during the studied period. Further studies are necessary to determine if the recent adoption of treatment algorithms in treating patients with CS will further impact in‐hospital mortality.

To determine the impact of socioeconomic status using median household income within the patient's community on rate of readmission among patients with heart failure (HF).We derived a study cohort of patients who were admitted from January 1, 2013, through December 31, 2014, with congestive HF from the Healthcare Cost and Utilization Project National Readmission Database. Patients were stratified into quartiles according to the estimated median household income of residents in the patient's ZIP Code (quartile 1, lowest; quartile 4, highest). The primary outcome was 30-day readmission. We used univariate and multivariate models to compare patients with respect to baseline characteristics, income quartiles, and 30-day readmission.About 20% (110,152 of 546,841) of patients with an index HF admission were readmitted within the first 30 days. Patients in the lowest income quartile had a higher readmission rate compared with those in the highest income quartile (21.1% [35,422 of 167,625] vs 19.5% [20,771 of 106,353]; P.001). Patients within the lowest income group had higher odds of readmission for cardiovascular causes compared with the highest income group (50.6% [17,923 of 35,422] vs 48.8% [10,136 of 20,771; P.001). Readmissions within the lowest income group accounted for 30% of all rehospitalization-related costs at $715 million. Multivariate analysis confirmed a higher rate of 30-day readmission among patients in the lowest income group compared with those in the highest group (adjusted odds ratio, 1.11; 95% CI, 1.08-1.13).Our study shows that patients in communities with the lowest quartile of income have a higher rate of readmission following the index HF admission with high associated costs. Readmission reporting and reimbursement adjustments should account for these socioeconomic inequalities.

Cancer is the second leading cause of death in the USA, and cardiovascular disease is the second leading cause of morbidity and mortality among cancer survivors. Cancer survivors share common risk factors for cardiovascular disease with non-cancer patients. With improved survival, cancer patients become susceptible to treatment-related toxicity often involving the heart. The impact of concurrent malignancy on outcomes particularly among heart failure patients is an area of active research. We studied the trends in the prevalence of a concurrent diagnosis of breast, prostate, colorectal, and lung cancer among admissions for acute heart failure and the associated trends for in-hospital mortality. Patients aged ≥ 18 years who were admitted with a primary diagnosis of “congestive heart failure” (CCS codes 99 and 108) from years 2003 to 2014 were included. We analyzed the rate of admission and in-hospital mortality among patients who had a concurrent diagnosis for either lung cancer, colorectal cancer, breast cancer (among females), or prostate cancer (among males). We performed a multivariate analysis to assess the role of a concurrent diagnosis of any cancer in predicting in-hospital mortality among HF admissions. From 2003 to 2014 across over 12 million HF admissions, ≈ 7% had a concurrent diagnosis of either lung, breast, colorectal, or prostate cancer. The prevalence was highest for breast cancer (2.3%) followed by prostate cancer (2.1%) and colorectal cancer (1.5%) and lowest with lung cancer (1.1%). The prevalence of cancer increased over the duration of study among all four cancer types with the largest increase in prevalence of breast cancer. Baseline comorbidities including hypertension, diabetes, smoking, chronic kidney disease, and coronary artery disease increased over time among patients with and without cancer. In-hospital mortality was higher among those with a diagnosis of lung cancer (5.9%) followed by colorectal cancer (4.0%), prostate cancer (3.5%), no diagnosis of cancer (3.3%), and breast cancer (3.2%). In-hospital mortality declined across HF admissions with and without a cancer diagnosis from 2003 to 2014. Decline in such mortality among heart failure was highest for patients with lung cancer (8.1 to 4.6% from 2003 to 2014; p

Obesity has been linked with increased incidence of atrial fibrillation (AF), but impact of presence of obesity on outcomes of hospitalizations for AF has not been investigated. We used the National Inpatient Sample database 2010 to 2014 to identify all adult hospitalizations aged >= 18 years with a primary diagnosis of AF. Obese patients were identified using the co-morbidity variable for obesity, as defined in National Inpatient Sample databases. Multivariable logistic regression was used to compare in-hospital outcomes (mortality, acute stroke events) between obese and non-obese patients with AF. Of 431, 734 hospitalizations for AF, 66,138 (15.3%) were obese. Obese patients were younger and more likely to be African-Americans compared with non-obese patients. Despite being younger, obese patients had significantly higher prevalence of cardiovascular co-morbidities such - as hypertension, diabetes mellitus, dyslipidemia, smoking, heart failure, and chronic renal failure (p

INTRODUCTION: Implantable cardioverter-defibrillator (ICD) in patients with heart failure with reduced ejection fraction reduces mortality secondary to malignant arrhythmias. Whether end-stage heart failure (HF) with continuous-flow left ventricular assist device (cf-LVAD) derive similar benefits remains controversial. METHODS: We performed a systematic literature review and meta-analysis of all published studies that examined the association between active ICDs and survival in advanced HF patients with cfLVAD. We searched PubMed, Medline, Embase, Ovid, and Cochrane for studies reporting the association between ICD and all-cause mortality in advanced HF patients with cfLVAD. Mantel-Haenszel risk ratio (RR) random-effects model was used to summarize data. RESULTS: Ten studies (9 retrospective and one prospective) with a total of 7,091 patients met inclusion criteria. There was no difference in all-cause mortality (RR 0.84, 95% CI 0.65–1.10, p=0.20, I(2) =62.40%), likelihood of survival to transplant (RR 1.07, 95% CI 0.98–1.17, p= 0.13, I(2) =0%), RV failure (RR 0.74, 95% CI 0.44–1.25, p = 0.26, I(2) =34%) between Active ICD and inactive/no ICD groups, respectively. Additionally, 27.5% received appropriate ICD shocks, while 9.5% received inappropriate ICD shocks. No significant difference was observed in terms of any complications between the two groups. CONCLUSIONS: All-cause mortality, the likelihood of survival to transplant, and worsening RV failure were not significantly different between active ICD and inactive/no ICD in cf-LVAD recipients. A substantial number of patients received appropriate ICD shocks suggesting a high-arrhythmia burden. The risks and benefits of ICDs must be carefully considered in patients with cf-LVAD.

PURPOSE OF REVIEW: Cancer and heart disease are the leading causes of mortality in the USA. Advances in cancer therapies, namely, the development and use of chemotherapeutic agents alone or in combination, are becoming increasingly prevalent. RECENT FINDINGS: Many chemotherapeutic agents have been associated with adverse cardiovascular manifestations. The mechanisms of these sequelae remain incompletely understood. In particular, microtubule inhibitor (MTI) agents have been related to the development of heart failure, myocardial ischemia, and conduction abnormalities. At present, there are no guidelines for patients undergoing MTI therapy as it pertains to both preventative and mitigatory strategies for cardiovascular complications. We conducted a literature review focusing on content related to the use of MTIs and their effect on the cardiovascular system. SUMMARY: MTIs have been associated with various forms of cardiotoxicity, and fatal cardiotoxicities are rare. The most well-described cardiotoxicities are brady- and tachyarrhythmias. The co-administration of anthracycline-based agents with MTIs can increase the risk of cardiotoxicity.

INTRODUCTION: Whether cardiac resynchronization therapy (CRT) continues to augment left ventricular remodeling in patients with the continuous-flow left ventricular assist device (cf-LVAD) remains unclear. METHODS: We performed a systematic review and meta-analysis of all clinical studies examining the role of continued CRT in end-stage heart failure patients with cf-LVAD reporting all-cause mortality, ventricular arrhythmias, and ICD shocks. Mantel-Haenszel risk ratio (RR) random-effects model was used to summarize data. RESULTS: Eight studies (7 retrospective and 1 randomized) with a total of 1,208 unique patients met inclusion criteria. There was no difference in all-cause mortality (RR 1.08, 95% CI 0.86 – 1.35, p = 0.51, I2=0%), all-cause hospitalization (RR 1.01, 95% CI 0.76-1.34, p = 0.95, I(2)=11%), ventricular arrhythmias (RR 1.08, 95% CI 0.83 – 1.39, p = 0.58, I(2) =50%) and ICD shocks (RR 0.87, 95% CI 0.57 – 1.33, p = 0.52, I(2) =65%) comparing CRT versus non-CRT. Subgroup analysis demonstrated significant reduction in ventricular arrhythmias (RR 0.76, 95% CI 0.64 – 0.90, p = 0.001) and ICD shocks (RR 0.65, 95% CI 0.44 – 0.97, p = 0.04) in “CRT on” group versus “CRT off” group. CONCLUSIONS: CRT was not associated with a reduction in all-cause mortality or increased risk of ventricular arrhythmias and ICD shocks compared to non-CRT in cf-LVAD patients. It remains to be determined which subgroup of cf-LVAD patients benefit from CRT. The findings of our study are intriguing, and therefore, larger studies in a randomized prospective manner should be undertaken to address this specifically.

Acute heart failure (HF) management is a complex and often involves a delicate balance of both cardiac and renal systems. Although pharmacologic diuresis is a mainstay of the pharmacologic management of decompensated HF, ultrafiltration (UF) represents a nonpharmacologic approach in the setting of diuretic resistance. We conducted a cross-sectional analysis of the 2009 through 2014 hospitalization data from the National Inpatient Sample. The study population consisted of hospitalizations with a discharge Diagnosis Related Groups of HF who were older than 18 years of age, did not have end-stage kidney disease, acute kidney injury and had not undergone hemodialysis or hemofiltration. There were 6,174 hospitalizations which included UF among the 7,799,915 hospitalizations for HF. Hospitalizations which included UF were among patients significantly younger in age (68.1 ± 1.0 vs 73.8 ± 0.1 years), male (61.9% vs 47.7%), and with higher prevalence of co-morbid conditions including chronic kidney disease (58% vs 31%), diabetes mellitus (53% vs 42%), and higher rates of co-morbidity (Charlson comorbidity score ≥2, 92% vs 80%). All-cause mortality was significantly higher among hospitalizations which included an UF (4.68% vs 2.24%). Hospitalizations with UF had a longer mean length of stay (6.2 vs 4.3 days, p

Patient: Male, 46-year-old Final Diagnosis: Varicella zoster virus infection Symptoms: Abdominal and/or epigastric pain Medication:— Clinical Procedure: Biopsy Specialty: Cardiology • Gastroenterology and Hepatology • Infectious Diseases • Transplantology Objective: Rare disease Background: Acute pancreatitis is rare following solid organ transplantation but is associated with high mortality. It has been most commonly reported following renal transplant but can occur with other solid organ transplantations. Case Report: A 46-year-old male who had an orthotopic heart transplant 6 months ago presented with a 3-week history of abdominal pain. The patient described it as intermittent, sharp, and stabbing, originating in the periumbilical area and radiating to the back. His lipase was elevated at 232 U/L. Given that the patient’s symptoms and lipase were elevated to greater than three times the upper limit of normal, he patient was diagnosed with acute pancreatitis. The patient also mentioned a diffuse itchy rash that started a few days prior to admission. Dermatology was consulted, and given the man’s clinical presentation, there was concern for atypical reactivation of varicella zoster virus (VZV). VZV polymerase chain reaction of the vesicles returned positive. The patient was started on acyclovir and his symptoms improved. Conclusions: This is the first reported case of VZV-associated pancreatitis in a heart transplant patient. Our patient presented with acute pancreatitis and was treated supportively. However, he did not receive antiviral treatment until his rash was discovered. Timely treatment of VZV resulted in resolution of both the rash and pancreatitis. Timely diagnosis of pancreatitis and VZV is important to prevent development of multiorgan failure and death.

The relationship between severity of obesity and outcomes in heart failure (HF) has long been under debate. We studied index HF admissions from the 2013–14 National Readmission Database. Admissions were separated into three weight-based categories: non-obese (Non-Ob), obese (Ob), and morbidly obese (Morbid-Ob) to analyze hospital mortality and readmission at 30 days and 6 months. We investigated etiologies and predictors of 30-day readmission among these weight categories. We studied a total of 578,213 patients of whom 3.0% died during index hospitalization (Non-Ob 3.3% vs. Ob 1.9% vs. Morbid-Ob 1.9%; p

The 30-day readmission rates, predictors, and outcomes for acute heart failure (AHF) patients are well published, but data beyond 30 days and the association between readmission-free period (RFP) and in-hospital readmission-related mortality remain unknown. We queried the National Readmission Database to analyze comparative outcomes of AHF. Patients were divided into three groups based on their RFP: group 1 (1-30 days), group 2 (31-90 days), and group 3 (91-275 days). AHF cases and clinical variables were identified using ICD-9 codes. The primary outcome was in-hospital mortality at the time of readmission. A total of 39,237 unplanned readmissions occurred within 275 days; 15,181 within group 1, 11,925 within group 2, and 12,131 within group 3. In-hospital mortality in groups 1, 2, and 3 were 7.4%, 5.1%, and 4.1% (p 0.001). Group 1 had higher percentages of patients with cardiogenic shock (1.3% vs. 0.9% vs. 0.9%; p 0.001), acute kidney injury (30.2% vs. 25.9% vs. 24.0%; p 0.001), dialysis use (8.6% vs. 7.5% vs. 6.9%; p 0.001), and non-ST elevation myocardial infarction (4.4% vs. 3.8% vs. 3.6%; p 0.001), but there was no statistical difference among the three groups for ST-elevation myocardial infarction, percutaneous coronary intervention (PCI), or ventricular assist device use at the time of index admission. However, group 3 had higher PCI (1.7%) compared with groups 1 and 2 (p 0.001). In multivariable logistic regression, groups 2 and 3 had odd ratio of 0.70 and 0.55, respectively, for in-hospital mortality compared with group 1. Longer RFP is associated with decreased risk of in-hospital mortality at the time of first readmission.

Cardiovascular disease, especially heart failure, is common among patients with kidney disease, and vice versa. Acute or chronic dysfunction of the heart or kidneys triggers and sustains dysfunction of the other, through a combination of hemodynamic, neurohormonal, sympathetic nervous system and biochemical feedback mechanisms, among others. Hemodynamic changes such as increased afterload, venous congestion, hypervolemia, decreased cardiac contractility, low cardiac output, and impaired renal perfusion are commonly noted among patients with cardiorenal dysfunction and are shown to have varying degrees of prognostic relevance. The gold standard test for invasive assessment of cardiac hemodynamics is right heart catheterization using the pulmonary artery catheter. In this chapter, we discuss the evidence surrounding several invasive hemodynamic parameters in acute and chronic cardiorenal syndrome. We review pre and postcapillary mechanisms contributing to the development of pulmonary hypertension in chronic kidney disease and explore the role for invasive hemodynamic assessment for guiding treatment among those affected by heart failure and/or pulmonary hypertension within this population.

Background: Renal dysfunction is an important predictor of poor outcomes in patients with heart failure with preserved ejection fraction (HFpEF). Right ventricular (RV) dysfunction is implicated as one of the explanations for worsening renal function in cardiorenal syndrome. Novel right heart catheterization (RHC) parameters such as pulmonary artery pulsatility index (PAPi) and right atrial to pulmonary capillary wedge pressure ratio (RA:PCWP) have been found as predictors of RV dysfunction. However, most studies investigating these parameters have been done in the setting of myocardial infarction or left ventricular assist device implantation, with limited data on these metrics in patients with HFpEF. Objective: The purpose of this study was to determine whether novel RHC parameters such as RA:PCWP and PAPi correlate with long-term renal outcomes among patients with HFpEF. Methods: A retrospective single-center study of adult patients with a documented diagnosis of heart failure who had RHC was performed between January 2006 and December 2010 at Einstein Med ical Center Philadelphia. Selected patients also had a serum B-type natriuretic peptide level ≥100 pg/mL and a PCWP ≥15 mm Hg. Patients with an ejection fraction < 50%, including those with recovered ejection fraction, and end-stage renal disease were excluded. Results: A total of 81 patients with a clinical diagnosis of HFpEF were identified who met the inclusion criteria. On multivariate analysis, after adjusting for age, sex, race, diabetes, hypertension, and cardiac index, PAPi was associated with long-term estimated glomerular filtration rate (eGFR) (β = 3.43, 95% CI = 0.635–6.23, p = 0.017), and RA:PCWP showed a trend towards significance (β = 14.81, 95% CI = –0.096–29.73, p = 0.051). The results were unchanged after further adjustment for eGFR at the time of RHC. Conclusion: Novel hemodynamic indices obtained by RHC may have predictive value for long-term renal dysfunction in patients with HFpEF.

To determine the readmission rate in patients with acute heart failure (AHF) discharged against medical advice (AMA).We performed a retrospective analysis using the 2014 National Readmission Database. Patients admitted with a primary diagnosis of AHF were selected. Only those discharged to home and who left AMA were included in the study. The primary outcome was 30-day readmission. We compared the readmission rates among those discharged AMA vs routinely discharged patients using propensity score matching (PSM) to address imbalance in variables between the 2 groups. We matched 3 routinely discharged patients to 1 patient who left AMA.We identified 273,489 patients with AHF, of whom 116,869 qualified for further study analysis. A total of 2014 patients (1.7%) were in the AMA group and 114,855 (98.3%) were in the routinely discharged group. After PSM, 6042 routinely discharged patients were matched with 2014 patients from the AMA group. The standard mean difference for each variable was less than 10% postmatching. The 30-day readmission rate among those who left AMA was higher than among those routinely discharged (33% vs 20.1%; P.001). Heart failure (44.8%) was the most common cause of readmission in the AMA group. Patients who left AMA were more likely to be readmitted to a different hospital compared with those routinely discharged (37.4 vs 23.1%; P.001). They also had a high rate of leaving AMA during the readmission (18 vs 2%; P.001).Patients with AHF discharged AMA had a significantly higher 30-day readmission rate than did the routinely discharged group.

BACKGROUND The utilization of cardiac resynchronization therapy defibrillator (CRT-D) has increased significantly, since its initial approval for use in selected patients with heart failure. Limited data exist as for current trends in implant-related in-hospital complications and cost utilization. The aim of our study was to examine in-hospital complication rates associated with CRT-D and their trends over the last decade. METHODS AND RESULTS Using the Nationwide Inpatient Sample, we estimated 378 248 CRT-D procedures from 2003 to 2012. We investigated common complications, including mechanical, cardiovascular, pericardial complications (hemopericardium, cardiac tamponade, or pericardiocentesis), pneumothorax, stroke, vascular complications (consisting of hemorrhage/hematoma, incidents requiring surgical repair, and accidental arterial puncture), and in-hospital deaths described with CRT-D, defining them by the validated International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code. Mechanical complications (5.9%) were the commonest, followed by cardiovascular (3.6%), respiratory failure (2.4%), and pneumothorax (1.5%). Age (≥65 years), female gender (OR, 95% CI; P value) (1.08, 1.03-1.13; 0.001), and the Charlson score ≥3 (1.52, 1.45-1.60

Background The clinical benefit of patent foramen ovale (PFO) closure after cryptogenic stroke has been a topic of debate for decades. Recently, 3 randomized controlled trials of PFO closure in patients with cryptogenic stroke demonstrated a significantly reduced risk of recurrent stroke compared with standard medical therapy alone. This meta-analysis was performed to clarify the efficacy of PFO closure for future stroke prevention in this population. Methods A systematic literature search was undertaken. Published pooled data from 5 large randomized clinical trials (CLOSE, RESPECT, Gore REDUCE, CLOSURE I, and PC) were combined and then subsequently analyzed. Enrolled patients with cryptogenic stroke were assigned to receive standard medical care or to undergo endovascular PFO closure, with a primary outcome of reduction in stroke recurrence rate. Secondary outcomes included rates of transient ischemic attack (TIA), composite outcome of stroke, TIA, and death from all causes, and rates of atrial fibrillation events. Results We analyzed data for 3412 patients. Transcatheter PFO closure resulted in a statistically significant reduced rate of recurrent stroke, compared with medication alone. Patients undergoing closure were 58% less likely to have another stroke. The number needed to treat with PFO closure to reduce recurrent stroke for 1 patient was 40. Conclusions Endovascular PFO closure was associated with a reduced risk of recurrent stroke in patients with a prior cryptogenic cerebral infarct. Although the absolute stroke reduction was small, these findings are clinically significant, given the young age of this patient population and the patients' lifetime risk of recurrent stroke.

Objective: To determine the rate and predictors of palliative care referral (PCR) in hospitalized patients with acute heart failure (AHF). Introduction: The PCR is commonly utilized in terminal conditions such as metastatic cancers. There is no data on trends and predictors from large-scale registry of general population regarding PCR in patients with AHF. Methods: For this retrospective study, data were obtained from National Inpatient Sample Database from 2010 to 2014. We used International Classification of Diseases, Ninth Revision diagnosis codes to identify cases with a principle diagnosis of AHF. These patients were divided into 2 groups: (1) PCR, (2) no PCR groups. We performed multivariate analysis to identify predictors of PCRs, as well as reported PCR trends from 2010 to 2014. Results: From the database, out of 37 312 324 hospitalizations, 621 947 unweighted cases with primary diagnosis of AHF were selected for further analysis. About 2.8% received PCR. From 2010 to 2014, there was an uptrend from 2.0% to 3.6% for PCR. Metastatic cancer, ventilator-dependent respiratory failure, and cardiogenic shock were strongly associated with PCR. Those who underwent percutaneous coronary intervention and African American or other races were negative predictors for PCR. In the PCR group, 31.4% of patients died during hospitalization. Conclusion: Palliative care referrals were made in a very small proportion of patients with AHF. We observed steady rise in the PCR utilization. Chronic conditions, advancing age, and high-risk patients were major predictors of PCR.

Left ventricular assist devices (LVADs) have emerged as an attractive option in patients with advance heart failure. Nationwide readmission database 2013 to 2014 was utilized to identify LVAD recipients using ICD-9 procedure code 37.66. The primary outcome was 90-day readmission. Readmission causes were identified using ICD-9 codes in primary diagnosis field. The secondary outcomes were LVAD associated with hospital complications. Hierarchic 2-level logistic models were used to evaluate study outcomes. We identified 4,693 LVAD recipients (mean age 57 years, 76.2% males). Of which 53.9% were readmitted in first 90 days of discharge. Cardiac causes (33.3%), bleeding (21.3%), and infections (12.4%) were leading etiologies of 90-day readmissions. Significant predictors (odds ratio, 95% confidence interval, p value) of readmission were disposition to nursing facilities (1.33, 1.09 to 1.63, p = 0.01) and longer length of stay (1.01, 1.00 to 1.01, p