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Acute decompensation of heart failure (HF) is often marked by fluid retention, and weight loss is a marker of successful diuresis. We examined the relationship between in-hospital weight loss and post-discharge outcomes in patients with HF.We conducted a propensity score-matched study of 8830 patients hospitalized for decompensated HF in the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry, in which 4415 patients in the weight-loss group and 4415 patients in the no-weight-loss group were balanced on 75 baseline characteristics. We defined weight loss as an admission-to-discharge weight loss of 1-30 kilograms, and we defined no weight loss as a weight gain or loss of1 kilogram. Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes associated with weight loss were estimated.Patients had a mean age of 78 years, 57% were women, and 11% were African American. The median weight loss in the weight-loss group was 3.6 (interquartile range, 2.0-6.0) kilograms. HRs and 95% CIs for 30-day all-cause mortality, all-cause readmission and HF readmission associated with weight loss were 0.75 (0.63-0.90), 0.90 (0.83-0.99) and 0.83 (0.72-0.96), respectively. Respective 60-day HRs (95% CIs) were 0.80 (0.70-0.92), 0.91 (0.85-0.98) and 0.88 (0.79-0.98). These associations were attenuated and lost significance during 6 months of follow-up.Among older patients hospitalized for decompensated HF, in-hospital weight loss was associated with a lower risk of mortality and hospital readmission. These findings suggest that in-hospital weight loss, a marker of successful diuresis and decongestion, is also a marker of improved clinical outcomes.

National heart failure (HF) guidelines recommend that in patients with HF with preserved ejection fraction (EF;HFpEF) and hypertension, systolic blood pressure (SBP) should be maintained below 130 mmHg. The objective of the study is to examine the association between initiation of anti-hypertensive drugs and outcomes in patients with HFpEF with persistent hypertension.Of the 8873 hospitalized patients with HFpEF (EF ≥50%) with a history of hypertension without renal failure in Medicare-linked OPTIMIZE-HF, 3315 had a discharge SBP ≥130 mmHg, of whom 1971 were not receiving anti-hypertensive drugs, thiazides and calcium channel blockers, before hospitalization. Of these, 366 received discharge prescriptions for those drugs. We assembled a propensity score-matched cohort of 365 pairs of patients initiated and not initiated on anti-hypertensive drugs, balanced on 37 baseline characteristics. Hazard ratios (HR) and 95% confidence intervals (CI) for outcomes associated with anti-hypertensive drug initiation were estimated in the matched cohort.Matched patients (n = 730) had a mean age of 78 years; 67% were women and 17% African Americans. During 6 (median 2.5) years of follow-up, 66% of the patients died and 45% had HF readmission. HRs (95% CIs) for all-cause mortality at 30 days, 12 months and 6 years associated with anti-hypertensive drug initiation were 0.64 (0.30-1.36), 0.70 (0.51-0.97), and 0.95 (0.79-1.13), respectively. Respective HRs (95% CIs) for HF readmission were 1.65 (0.97-2.80), 1.18 (0.90-1.56) and 1.09 (0.88-1.35).Among hospitalized older patients with HFpEF with uncontrolled hypertension, the initiation of therapy with anti-hypertensive drugs was not associated with all-cause mortality or hospital readmission.

Background In patients with heart failure with reduced ejection fraction (HFrEF) and hypertension, systolic blood pressure is recommended to be maintained below 130 mmHg, although this has not been shown to be associated with improved outcomes. We examined the association of anti-hypertensive drug initiation and outcomes in patients with HFrEF. Methods In the Medicare-linked OPTIMIZE-HF, 7966 patients with HFrEF (ejection fraction ≤40%) without renal failure were not receiving anti-hypertensive drugs before hospitalization, of whom 692 received discharge prescriptions for those drugs (thiazides and calcium channel blockers). We assembled a propensity score-matched cohort of 687 pairs of patients initiated and not initiated on anti-hypertensive drugs, balanced on 38 baseline characteristics. Hazard ratios (HR) and 95% confidence intervals (CI) for outcomes associated with anti-hypertensive drug initiation were estimated in matched cohort. Results Matched patients (n=1374) had a mean age of 74 years, 41% were women, 17% were African American, 66% were discharged on renin-angiotensin system inhibitors and beta blockers, and 10% on aldosterone antagonists. During 6 (median 2.5) years of follow-up, 70% of the patients died and 53% had heart failure readmission. Anti-hypertensive drug initiation was not significantly associated with all-cause mortality (HR, 0.95; 95% CI, 0.83–1.07) or heart failure readmission (HR, 0.93; 95% CI, 0.80–1.07). Similar associations were observed during 30 days and 12 months of follow-up. Conclusions Among hospitalized older patients with HFrEF receiving contemporary treatments for heart failure, initiation of an anti-hypertensive drug was not associated with a lower risk of all-cause mortality or hospital readmission.

Background: Beta-blockers improve clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF). Less is known about their role in older nursing home residents with HFrEF. Methods: From the combined OPTIMIZE-HF and Alabama Heart Failure Project datasets, we assembled a propensity score-matched balanced cohort of 6494 hospitalized patients ≥65 years with HFrEF (ejection fraction ≤40%). In our primary approach, hazard ratios (HR) and 95% confidence intervals (CI) for outcomes associated with discharge prescriptions for beta-blockers were estimated, examining for heterogeneity by admission from nursing homes. In our sensitivity approach, we examined these associations in a separately assembled propensity score-matched cohort of 122 patients admitted from nursing homes. Results: In the matched primary cohort of 6494 patients, HRs (95% CIs) for 12-month all-cause mortality and heart failure readmission were 0.80 (0.74–0.87) and 0.94 (0.86–1.02), respectively. Respective HRs (95% CIs) in the nursing home and non-nursing home subgroups were 0.77 (0.51–1.16) and 0.81 (0.74–0.87) for all-cause mortality (interaction p, 0.653) and 1.06 (0.53–2.12) and 0.89 (0.82–0.96) for heart failure readmission (interaction p, 0.753). In the matched sensitivity cohort of 122 patients admitted from nursing homes, HRs (95% CIs) for 12-month all-cause mortality and heart failure readmission were 0.86 (0.55–1.35) and 1.07 (0.52–2.22), respectively. Similar associations were observed for 30-day outcomes. Conclusions: Beta-blocker use was associated with a lower risk of all-cause mortality but not of heart failure readmission in older patients with HFrEF, which were similar for patients admitted and not admitted from nursing homes.

To examine the association between income and cardiovascular disease (CVD) in community-dwelling older adults.Of the 5795 Medicare-eligible community-dwelling older Americans aged 65-100 years in the Cardiovascular Health Study (CHS), 4518 (78%) were free of baseline CVD, defined as heart failure, acute myocardial infarction, stroke, or peripheral arterial disease. Of them, 1846 (41%) had lower income, defined as a total annual household income$16,000. Using propensity scores for lower income, estimated for each of the 4518 participants, we assembled a matched cohort of 1078 pairs balanced on 42 baseline characteristics. Outcomes included centrally adjudicated incident CVD and mortality.Matched participants (n = 2156) had a mean age of 73 years, 63% were women, and 13% African American. During an overall follow-up of 23 years, incident CVD, all-cause mortality and the combined endpoint of incident CVD or mortality occurred in 1094 (51%), 1726 (80%) and 1867 (87%) individuals, respectively. Compared with the higher income group, hazard ratio (HR) for time to the first occurrence of incident CVD in the lower income group was 1.16 with a 95% confidence interval (CI) of 1.03 to 1.31. A lower income was also associated with a significantly higher risk of all-cause mortality (HR, 1.19; 95% CI, 1.08-1.30), and consequently a higher risk of the combined endpoint of incident CVD or death (HR, 1.20; 95% CI, 1.09-1.31).Among community-dwelling older Americans free of baseline CVD, an annual household income$16,000 is independently associated with significantly higher risks of new-onset CVD and death.

Background A low right ventricular ejection fraction (RVEF) is a marker of poor outcomes in patients with heart failure with reduced ejection fraction (HFrEF). Beta-blockers improve outcomes in HFrEF, but whether this effect is modified by RVEF is unknown. Methods and Results Of the 2798 patients in Beta-Blocker Evaluation of Survival Trial (BEST), 2008 had data on baseline RVEF (mean 35%, median 34%). Patients were categorized into an RVEF of less than 35% (n = 1012) and an RVEF of 35% or greater (n = 996). We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) within each RVEF subgroup and formally tested for interactions between bucindolol and RVEF. The effect of bucindolol on all-cause mortality in 2008 patients with baseline RVEF (HR 0.88, 95% CI 0.75–1.02) is consistent with that in 2798 patients in the main trial (HR 0.90, 95% CI 0.78–1.02). Bucindolol use was associated with a lower risk of all-cause mortality in patients with an RVEF of 35% or greater (HR 0.70, 95% CI 0.55–0.89), but not in those with an RVEF of less than 35% (HR 1.02, 95% CI 0.83–1.24, P for interaction = .022). Similar variations were observed for cardiovascular mortality (P for interaction = .009) and sudden cardiac death (P for interaction = .018), but not for pump failure death (P for interaction = .371) or HF hospitalization (P for interaction = .251). Conclusions The effect of bucindolol on mortality in patients with HFrEF was modified by the baseline RVEF. If these hypothesis-generating findings can be replicated using approved beta-blockers in contemporary patients with HFrEF, then RVEF may help to risk stratify patients with HFrEF for optimization of beta-blocker therapy.

BACKGROUND Due to anatomic and physiologic concerns, prior generations of the left ventricular assist devices (LVAD) have frequently been denied to patients with small body size. However, outcomes in patients with small body surface area (BSA) following HeartMate 3 (HM3) LVAD implantation remain relatively unknown. METHODS A cohort of 220 patients implanted at a single center was divided into two groups: BSA ≤1.8 m2 (small BSA, n = 37) and BSA >1.8 m2 (large BSA, n = 183). We investigated baseline characteristics and clinical outcomes including survival and incidence of adverse events. RESULTS Small BSA patients were older (60 vs. 57 years), more likely female (60% vs. 20%), had a lower body mass index (24 vs. 32 kg/m2 ), lower incidence of diabetes (32% vs. 51%), history of stroke (5% vs. 19%), and left ventricular thrombus (0% vs. 11%). They had smaller left ventricular end diastolic diameter (64.8 vs. 69.3 mm). Pump speed and pump flows at discharge were lower in the small BSA group. Survival at 1 year and 2 years was 86% versus 87% and 86% versus 79% for small versus large BSA groups (p = 0.408), respectively. The rates of adverse events were similar between groups and there were no cases of confirmed pump thrombosis. The incidence of readmissions for low flow alarms was higher in the small BSA group (0.55 vs. 0.24 EPPY). CONCLUSIONS These findings demonstrate comparable outcomes in patients with small body size and suggest that this parameter should not be an exclusion criterion on patients who are otherwise candidates for HM3 LVAD implantation.

IntroductionHospital length of stay (LoS) and hospital readmissions are metrics of healthcare performance. We examined the association between these two metrics in older patients hospitalized with decompensated heart failure (HF).Material and methodsEight thousand and forty-nine patients hospitalized for HF in 106 U.S. hospitals had a median LoS of 5 days; among them, 3777 had a LoS > 5 days. Using propensity scores for LoS > 5 days, we assembled 2723 pairs of patients with LoS 1–5 vs. > 5 days. The matched cohort of 5446 patients was balanced on 40 baseline characteristics. We repeated the above process in 7045 patients after excluding those with LoS > 10 days, thus assembling a second matched cohort of 2399 pairs of patients with LoS 1–5 vs. 6–10 days. Hazard ratios (HR) and 95% confidence intervals (CI) for outcomes associated with longer LoS were estimated in matched cohorts.ResultsIn the primary matched cohort (n = 5446), LoS > 5 days was associated with a higher risk of all-cause readmission at 30 days (HR = 1.16; 95% CI: 1.04–1.31; p = 0.010), but not during longer follow-up. A longer LoS was also associated with a higher risk of mortality during 8.8 years of follow-up (HR = 1.13; 95% CI: 1.06–1.21; p < 0.001). LoS had no association with HF readmission. Similar associations were observed among the matched sensitivity cohort (n = 4798) that excluded patients with LoS > 10 days.ConclusionsIn propensity score-matched balanced cohorts of patients with HF, a longer LoS was independently associated with poor outcomes, which persisted when LoS > 10 days were excluded.

The effect of loop diuretics on clinical outcomes in heart failure has not been evaluated in randomized controlled trials. In hospitalized patients with heart failure, a discharge loop diuretic prescription has been shown to be associated with improved 30-day outcomes, which appears to be more pronounced in subgroups with congestion. In the current study, we examined these associations and association modifications during longer follow-up.We assembled a propensity score-matched cohort of 2191 pairs of hospitalized heart failure patients discharged with, vs without, a prescription for loop diuretics, balanced on 74 baseline characteristics (mean age 78 years; 54% women; 11% African American).Hazard ratio (HR) and 95% confidence interval (CI) for 6-year combined endpoint of heart failure readmission or all-cause mortality was 1.02 (0.96-1.09). HRs and 95% CIs for this combined endpoint in patients with no, mild-to-moderate, and severe pulmonary rales were 1.19 (1.07-1.33), 0.95 (0.86-1.04), and 0.77 (0.63-0.94), respectively (P for interaction,.001). Respective HRs (95% CIs) for no, mild-to-moderate, and severe lower extremity edema were 1.16 (1.06-1.28), 0.94 (0.85-1.04), and 0.71 (0.56-0.89; interaction P.001).The association between a discharge loop diuretic prescription and long-term clinical outcomes in hospitalized patients with heart failure is modified by admission congestion with worse, neutral, and better outcomes in patients with no, mild-to-moderate, and severe congestion, respectively. If these findings can be replicated, congestion may be used to risk-stratify patients with heart failure for potential optimization of loop diuretic prescription and outcomes.

Heart failure (HF) is a risk factor for incident stroke. However, less is known about the independent nature of this association and to what extent various baseline characteristics may mediate this risk. Of the 5,795 community-dwelling adults aged ≥65 years in the Cardiovascular Health Study, 5,448 were free of baseline stroke, of whom 229 had baseline HF. We used a multivariable-adjusted Cox regression model to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for centrally adjudicated incident stroke associated with HF. Participants had a mean age of 73 years, 58% were women, and 15% were African-American. During 23 years of follow-up, incident stroke occurred in 18.8% and 19.3% of those with and without HF, respectively, but the time to first stroke was shorter in those with HF (age-gender-race-adjusted HR 1.64, 95% CI 1.21 to 2.25). The association remained essentially unchanged after adjustments for tobacco, alcohol, and physical activity (HR 1.63, 95% CI 1.21 to 2.24), attenuated after adjustment for hypertension, atrial fibrillation, myocardial infarction, and diabetes mellitus (HR 1.26, 95% CI 0.92 to 1.72), and further attenuated after additional adjustment for 10 baseline functional and subclinical variables (HR 1.05, 95% CI 0.76 to 1.46). In conclusion, despite a similar 23-year stroke incidence, time to first stroke was shorter in older adults with HF than without. However, this extra risk appears to be mediated primarily by 4 cardiovascular diseases that are also risk factors for HF. These findings highlight the importance of the primary prevention of these HF risk factors to reduce the extra risk of stroke in HF.

BACKGROUND: New hypertension and heart failure guidelines recommend that systolic blood pressure (SBP) in patients with heart failure with preserved ejection fraction (HFpEF) and hypertension be lowered to

Sustained ventricular tachycardia and ventricular fibrillation (VF) are life-threatening arrhythmias which remain highly prevalent in patients with advanced heart failure. These ventricular arrhythmias may impair the support provided by continuous-flow left ventricular assist devices (CF-LVADs) and lead to frequent hospitalizations, antiarrhythmic medication use, external defibrillations, and need for heart transplantation. We report a case in which a patient with a CF-LVAD and an implantable cardioverter defibrillator at end of life presented with asymptomatic low-flow alarms and was found to have VF of unknown duration. Unique in our case was the presence of apparent organized contractility and rhythmic opening of the mitral valve on echocardiogram despite VF on electrocardiogram.

Background Digoxin reduces the risk of heart failure hospitalization but has no effect on mortality in patients with heart failure without atrial fibrillation in the randomized controlled trial setting. Observational studies of digoxin use in patients with atrial fibrillation have suggested a higher risk for poor outcomes. Less is known about this association in patients with heart failure and atrial fibrillation, the examination of which was the objective of the current study. Methods We conducted an observational propensity score-matched study of predischarge digoxin initiation in 1768 hospitalized patients with heart failure and atrial fibrillation in the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry, balanced on 56 baseline characteristics (mean age, 79 years; 55% women; 7% African American). Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes were estimated for the 884 patients initiated on digoxin compared with 884 not initiated on digoxin. Results HRs (95% CIs) for 30-day, 2-year, and 4-year all-cause mortality were 0.80 (0.55-1.18; P = .261), 0.94 (0.87-1.16; P = .936), and 1.01 (0.90-1.14; P = .729), respectively. Respective HRs (95% CIs) for heart failure readmission were 0.67 (0.49-0.92; P = .014), 0.81 (0.69-0.94; P = .005), and 0.85 (0.74-0.97; P = .022), and those for all-cause readmission were 0.78 (0.64-0.96; P = .016), 0.90 (0.81-1.00; P = .057), and 0.91 (0.83-1.01; P = .603). These associations were homogeneous between patients with left ventricular ejection fraction ≤45% vs >45%. Conclusions Among hospitalized older patients with heart failure (HFrEF and HFpEF) and atrial fibrillation, initiation of digoxin was associated with a lower risk of heart failure readmission but had no association with mortality.

Background Heart failure (HF) and breast cancer are 2 of the leading causes of death in postmenopausal women. The temporal association between HF and breast cancer in postmenopausal women has not been described. Objectives This study sought to examine the temporal association between HF and breast cancer. Methods Postmenopausal women within the WHI (Women’s Health Initiative) cohort were studied. All prevalent HF and prevalent breast cancer at enrollment were self-reported. Incident hospitalized HF and breast cancer diagnoses were adjudicated through 2017. Results Among a cohort of 44,174 women (mean age 63 ± 7 years), 2,188 developed incident invasive breast cancer and 2,416 developed incident hospitalized HF over a median follow-up of 14 and 15 years, respectively. When compared with a breast cancer- and HF-free cohort, there was no association between prevalent HF and incident invasive breast cancer and similarly, there was no association between prevalent breast cancer and incident hospitalized HF. Across the entire cohort, the median survival after incident hospitalized HF was worse compared with an incident invasive breast cancer diagnosis (5 and 19 years, respectively). In women with incident invasive breast cancer, prevalent HF was associated with an increased risk of mortality (hazard ratio: 2.28; 95% confidence interval: 1.31 to 3.95). In women with incident hospitalized HF, prevalent breast cancer was associated with an increased risk of mortality (hazard ratio: 1.66; 95% confidence interval: 1.03 to 2.68). Cause of death after incident HF was different only in women with prevalent and interim breast cancer compared with those without prevalent and interim breast cancer. Conclusions In postmenopausal women, prevalent HF was not associated with a higher incidence of breast cancer and vice versa. However, the presence of incident invasive breast cancer or incident HF in those with prevalent HF or prevalent breast cancer, respectively, was associated with increased mortality., Central Illustration

Background Digoxin reduces the risk of heart failure hospitalization in patients with heart failure with reduced ejection fraction. Less is known about this association in patients with heart failure with preserved ejection fraction (HFpEF), the examination of which was the objective of the current study. Methods In the Medicare-linked OPTIMIZE-HF registry, 7374 patients hospitalized for HF had ejection fraction ≥50% and were not receiving digoxin prior to admission. Of these, 5675 had a heart rate ≥50 beats per minute, an estimated glomerular filtration rate ≥30 mL/min/1.73 m2 or did not receive inpatient dialysis, and digoxin was initiated in 524 of these patients. Using propensity scores for digoxin initiation, calculated for each of the 5675 patients, we assembled a matched cohort of 513 pairs of patients initiated and not initiated on digoxin, balanced on 58 baseline characteristics (mean age, 80 years; 66% women; 8% African American). Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes associated with digoxin initiation were estimated in the matched cohort. Results Among the 1026 matched patients with HFpEF, 30-day heart failure readmission occurred in 6% and 9% of patients initiated and not initiated on digoxin, respectively (HR 0.70; 95% CI, 0.45-1.10; P = .124). HRs (95% CIs) for 30-day all-cause readmission and all-cause mortality associated with digoxin initiation were 0.95 (0.73-1.23; P = .689) and 0.93 (0.55-1.56; P = .773), respectively. Digoxin initiation had no association with 6-year outcomes. Conclusion Digoxin initiation prior to hospital discharge was not associated with 30-day or 6-year outcomes in older hospitalized patients with HFpEF.

Background Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs-ARBs) improve outcomes in heart failure (HF). Less is known about this association in nursing home (NH) residents. Methods Of the 8024 hospitalized HF patients, 542 were NH residents, of whom 250 received ACEIs-ARBs. We assembled a propensity score-matched cohort of 157 pairs of NH residents receiving and not receiving ACEIs-ARBs balanced on 29 baseline characteristics (mean age, 83 years, 74% women, 17% African American), in which we estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes associated with ACEI-ARB use. We then checked for interaction in a matched cohort of 5130 patients (378 were NH residents) assembled from the 8024 patients. Results Among 314 matched NH residents, HRs (95% CIs) for 30-day all-cause readmission, HF readmission, and all-cause mortality were 0.78 (0.47-1.28), 0.68 (0.29-1.60), and 1.26 (0.70-2.27), respectively. Respective HRs (95% CIs) at 1 year were 0.76 (0.56-1.02), 0.68 (0.42-1.09), and 1.04 (0.78-1.38). Among 5130 matched patients, ACEI-ARB use was associated with a significantly lower risk of all outcomes at both times, with no significant interactions, except for 1-year mortality, which was only significant in the non-NH subgroup (P for interaction, 0.026). Conclusions We found no evidence that the use of ACEIs or ARBs is associated with improved outcomes in patients with HF in the NH setting. However, we also found no evidence that this association is different in NH residents with HF versus non-NH patients with HF. Future larger studies are needed to demonstrate effectiveness of these drugs in the NH setting.

Early generation left ventricular assist devices (LVAD) for treatment of refractory heart failure attempted to mimic the pulsatility of a native heart and were bulky and less durable due to valves within the inflow and outflow pathways. The next disruption came with the introduction of continuous flow pumps characterized by a low-pulse pressure circulation. Since the mechanism of action did not involve displacement of blood, these pumps were much smaller and less noisy in part due to fewer moving parts. Such devices include the HeartMate II axial-flow pathway pump which is implanted thoraco-abdominally and the HVAD, a centrifugal-flow pathway pump which is smaller and is implanted entirely within the thoracic cavity and uses a combination of hydrodynamic and magnetic levitation of the internal rotor. These pumps improved survival compared with the early generation LVADs and in a trial, the HVAD demonstrated non-inferiority compared with the HeartMate II but with an increase in ischemic and hemorrhagic strokes. The HeartMate 3 LVAD is an intrapericardial centrifugal-flow pathway pump with a full magnetically levitated, frictionless rotor with a fixed intrinsic pulse. In a randomized trial, the HeartMate 3 "hybrid" pump was associated with near-elimination of pump thrombosis, a reduction in strokes of any type or severity and lower mucosal bleeding rates. Despite improvements in hemocompatibility, right heart failure and infections contribute to significant morbidity, and devices designed to be internally contained with a wireless power source and physiological flow characteristics are still required despite great strides in the field.

Continuous infusion of ambulatory inotropic therapy (AIT) is increasingly used in patients with end-stage heart failure (HF). There is a paucity of data concerning the concomitant use of beta-blockers (BB) in these patients.We retrospectively reviewed all patients discharged from our institution on AIT. The cohort was stratified into 2 groups based on BB use. The 2 groups were compared for differences in hospitalizations due to HF, ventricular arrhythmias and ICD therapies (shock or antitachycardia pacing).Between 2010 and 2017, 349 patients were discharged on AIT (95% on milrinone); 74% were males with a mean age of 61 ± 14 years. BB were used in 195 (56%) patients, whereas 154 (44%) did not receive these medications. Patients in the BB group had longer duration of AIT support compared to those in the non-BB group (141 [1-2114] vs 68 [1-690] days). After adjusting for differences in baseline characteristics and indication for AIT, patients in the BB group had significantly lower rates of hospitalizations due to HF (hazard ratio [HR] 0.61 (0.43-0.86); P = 0.005), ventricular arrhythmias (HR 0.34 [0.15-0.74]; P = 0.007) and ICD therapies (HR 0.24 [0.07-0.79]; P = 0.02).In patients with end-stage HF on AIT, the use of BB with inotropes was associated with fewer hospitalizations due to HF and fewer ventricular arrhythmias.

OBJECTIVES The influence of preoperative left ventricular size in outcomes following centrifugal-flow left ventricular assist device (LVAD) implantation has not been well characterized. METHODS A cohort of 313 patients who received a centrifugal-flow LVAD at a single institution was analysed. Using a maximally selected log-rank statistic, we investigated whether a left ventricular end-diastolic dimension (LVEDD) cut-off point was associated with worse outcomes. The cohort was then divided in 2 groups based on the LVEDD cut-off point. RESULTS An LVEDD cut-off point of 59 mm was found to predict worse survival. Smaller LVEDD patients (≤59 mm, N = 52) were older and more likely to have a history of coronary artery disease compared those with a larger LVEDD (>59 mm, N = 261). Smaller LVEDD patients had lower survival compared to larger LVEDD patients (71% vs 85% at 1 year and 58% vs 80% at 2 years, P = 0.003). The need for temporary right ventricular mechanical support was significantly higher in the smaller LVEDD cohort (11.5% vs 1.9%, P = 0.002). Pump flows at time of discharge were lower in the smaller LVEDD group (3.8 vs 4.2 l/min, P = 0.005), who also had a higher incidence of late right ventricular failure (23% vs 12%, P = 0.02), higher rates of gastrointestinal bleeding (0.416 vs 0.256 events per patient-year, P = 0.025) and higher readmissions secondary to low flow alarms (0.429 vs 0.240 events per patient-year, P = 0.007). Multivariable analysis demonstrated that smaller LVEDD, older age, high BUN and high bilirubin levels were independent predictors of worse survival. CONCLUSIONS In patients receiving a centrifugal-flow LVAD, smaller preoperative LVEDD (≤59 mm) was associated with lower survival and higher incidence of adverse outcomes.

Heart failure (HF) is the leading cause for 30-day all-cause readmission in older Medicare beneficiaries and 30-day all-cause readmission is associated with a higher risk of mortality. In the current analysis, we examined if that association varied by timing of 30-day all-cause readmission. Of the 8,049 Medicare beneficiaries hospitalized for HF, 1,688 had 30-day all-cause readmissions, of whom 1,519 were alive at 30 days. Of these, 626 (41%) had early (first 10 days) 30-day readmission. Propensity scores for early 30-day readmission, estimated for all 1,519 patients, were used to assemble a matched cohort of 596 pairs of patients with early versus late (11 to 30 days) all-cause readmission balanced on 34 baseline characteristics. Two-year all-cause mortality occurred in 51% and 57% of matched patients with early versus late 30-day all-cause readmissions, respectively (hazard ratio [HR] associated with late 30-day readmission, 1.22; 95% confidence interval [CI], 1.04 to 1.42; p = 0.014). This association was not observed in the subset of 436 patients whose 30-day all-cause readmission was due to HF (HR, 1.01; 95% CI, 0.79 to 1.28; p = 0.963), but was observed in the subset of 756 patients whose 30-day all-cause readmission was not due to HF (HR, 1.37; 95% CI, 1.12 to 1.67; p = 0.002; p for interaction, 0.057). In conclusion, in a high-risk subset of older hospitalized HF patients readmitted within 30 days, readmission during 11 to 30 (vs 1 to 10) days was associated with a higher risk of death and this association appeared to be more pronounced in those readmitted for non-HF-related reasons.

Background Beta-blockers in high target doses are recommended for heart failure with reduced ejection fraction (HFrEF) but not for preserved ejection fraction (HFpEF). Treatment benefits are often more pronounced in high-risk subgroups, and patients with HFpEF with heart rate ≥70 beats per minute have emerged as such a high-risk subgroup. We examined the associations of high-dose beta-blocker use with outcomes in these patients. Methods Of the 8462 hospitalized patients with heart failure with ejection fraction ≥50% in the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry, 5422 had a discharge heart rate ≥70 beats per minute. Of these, 4537 had no contraindications to beta-blocker use, of which 2797 (2592 with dose data) received prescriptions for beta-blockers. Of the 2592, 730 received high-dose beta-blockers, defined as atenolol ≥100 mg/day, carvedilol ≥50 mg/day, metoprolol tartrate or succinate ≥200 mg/day, or bisoprolol ≥10 mg/day, and 1740 received no beta-blockers. Using propensity scores for the receipt of high-dose beta-blockers, we assembled a matched cohort of 1280 patients, balanced on 58 characteristics. Results All-cause mortality occurred in 63% and 68% of matched patients receiving high-dose beta-blocker vs no beta-blocker, respectively, during 6 years (median, 2.8) of follow-up (hazard ratio, 0.86; 95% confidence interval, 0.75-0.98; P = .027). The hazard ratios (95% confidence intervals) for all-cause readmission and the combined endpoint of all-cause readmission or all-cause mortality associated with high-dose beta-blocker use were 0.90 (0.81-1.02) and 0.89 (0.80-1.00), respectively. Conclusions In patients with HFpEF and heart rate ≥70 beats per minute, high-dose beta-blocker use was associated with a significantly lower risk of death. Future randomized controlled trials are needed to examine this association.

Background: According to the ACC/AHA HF guideline, in patients (pts) with HFpEF and HTN, optimal systolic blood pressure (SBP) target is Methods: Of the 8873 hospitalized pts with HF w EF ≥50% in Medicare-linked OPTIMIZE-HF, 6781 (76%) had a history of HTN, of whom 3680 (54%) had a discharge SBP ≥130 mmHg. We assembled an inception cohort by excluding 1611 (44%) receiving anti-HTN drugs (HCTZ, hydralazine, or a CCB) before admission. Of the remaining 2069 pts, 430 (21%) received a new discharge prescription for anti-HTN drugs. Propensity scores for anti-HTN drug initiation, estimated for each of the 2069 pts, were used to assemble a cohort of 427 pairs of pts started and not started on anti-HTN therapy, balanced on 60 baseline characteristics including use of ACEI/ARBs and BBs. Results: The 854 matched pts had a mean age of 77 years, mean SBP of 149 mmHg, 67% were women, and 17% African American. 3-year all-cause mortality occurred in 45% and 53% of matched pts started vs. not started on anti-HTN therapy, resp. (HR 0.77; 95% CI, 0.64-0.94; p=0.009; Figure ). There was no association with readmissions. Conclusion: In pts with HFpEF, HTN and SBP ≥130 mm Hg, initiation of anti-HTN therapy is associated with a lower risk of death.

Sustained ventricular tachycardia and ventricular fibrillation (VF) are life-threatening arrhythmias which remain highly prevalent in patients with advanced heart failure. These ventricular arrhythmias may impair the support provided by CF-LVADs and lead to frequent hospitalizations, antiarrhythmic medication use, external defibrillations, and need for heart transplantation. We report a case in which a patient with a CF-LVAD and an ICD at end-of-life (EOL) presented with asymptomatic low-flow alarms and was found to have VF of unknown duration. Unique in our case was the presence of organized contractility and rhythmic opening of the mitral valve on echocardiogram despite VF on ECG.

Heart failure (HF) is a major source of morbidity and mortality. Fluid retention and shortness of breath are its cardinal manifestations for which loop diuretics are used. Although their usefulness is well accepted, less is known about their role in improving clinical outcomes.The purpose of this study was to determine the relationship between loop diuretics and clinical outcomes in patients with HF.Of the 25,345 older patients hospitalized for HF in the Medicare-linked OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry, 9,866 (39%) received no pre-admission diuretics. The study excluded 1,083 patients receiving dialysis and 847 discharged on thiazide diuretics. Of the remaining 7,936 patients, 5,568 (70%) were prescribed loop diuretics at discharge. Using propensity scores for receipt of loop diuretics estimated for each of the 7,936 patients, a matched cohort of 2,191 pairs of patients was assembled balanced on 74 baseline characteristics. Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes were estimated in the matched cohort.Matched patients (n = 4,382) had a mean age of 78 years, 54% were women, and 11% were African American. The 30-day all-cause mortality occurred in 4.9% (107 of 2,191) and 6.6% (144 of 2,191) of patients in the loop diuretic and no loop diuretic groups, respectively (HR when the use of loop diuretics was compared with nonuse: 0.73; 95% CI: 0.57 to 0.94; p = 0.016). Patients in the loop diuretic group had a significantly lower risk of 30-day HF readmission (HR: 0.79; 95% CI: 0.63 to 0.99; p = 0.037) but not of 30-day all-cause readmission (HR: 0.89; 95% CI: 0.79 to 1.01; p = 0.081). None of the associations was statistically significant during 60 days of follow-up.Hospitalized older patients not taking diuretics prior to hospitalization for HF decompensation who received a discharge prescription for loop diuretics had significantly better 30-day clinical outcomes than those not discharged on loop diuretics. These findings provide new information about short-term clinical benefits associated with loop diuretic use in HF.

BACKGROUND: Digoxin use has been associated with a lower risk of 30‐day all‐cause admission and readmission in patients with heart failure and reduced ejection fraction (HFrEF). HYPOTHESIS: Digoxin use will be associated with improved outcomes in patients with HFrEF receiving β‐blockers. METHODS: Of the 3076 hospitalized Medicare beneficiaries with HFrEF (EF

Iatrogenic chordal rupture with severe mitral regurgitation is a rare but serious complication associated with the use of Impella device. We present a case of a 47-year-old man with ischemic cardiomyopathy who required insertion of an Impella 5.0 device. During Impella support, he developed acute pulmonary edema secondary to newly diagnosed posterior mitral valve chordal rupture and subsequent severe mitral regurgitation. He underwent implantation of a durable left ventricular assist device with concomitant edge-to-edge mitral valve repair through the apex.

Purpose To evaluate early hemocompatibility-related outcomes after implementation of a low anti-Xa target heparin protocol following implantation of the HeartMate 3 Left Ventricular Assist Device (LVAD). Methods We reviewed hemocompatibility-related outcomes including mediastinal bleeding, gastrointestinal bleeding (GIB), stroke, and pump thrombosis (PT) events in recipients of HeartMate 3 LVADs before and after implementation of a low anti-Xa target heparin protocol. The higher anti-Xa protocol targeted levels of 0.3-0.5 IU/ml using a starting dose of 18 units/kg/hr with a maximum starting dose of 1530 units/hr, and the lower anti-Xa protocol targeted levels of 0.1-0.3 IU/ml using a starting dose of 7 units/kg/hr with a maximum starting dose of 595 units/hr. Results Between 9/2018 and 8/2020, 152 patients were implanted with a HeartMate 3. Mean patient age was 57 ± 12 years, 74% were males, and 76% of patients were African American. Per our center's protocol, IV heparin was started on postoperative day 5. 106 patients were treated with the higher anti-Xa protocol and 21 patients were treated with the lower anti-Xa protocol. The patients treated with the higher anti-Xa target protocol experienced 10 (9.4%) post-operative mediastinal bleeding events requiring return to the operating room (OR) while patients on the lower anti-Xa protocol experienced none. Patients treated with the higher anti-Xa target protocol experienced 8 (7.5%) GIB events within 60 days of implant while patients on the lower anti-Xa protocol experienced no GIB. Patients treated with the higher anti-Xa protocol experienced one hemorrhagic stroke and no ischemic strokes, while patients on the lower anti-Xa protocol experienced one ischemic stroke and no hemorrhagic strokes. No PT events requiring pump exchange occurred in either group. Conclusion Implementation of a low anti-Xa target heparin protocol after HeartMate 3 LVAD implantation surgery was associated with a lower incidence of mediastinal and GI bleeding. No PT events requiring pump exchange were observed in either group. Stroke rate was low in both groups. Further research is needed to determine the safest and most effective anticoagulation protocol after HeartMate 3 implantation that lowers the incidence of early hemocompatibility-related events.

Aims To examine associations of below-target and target dose of enalapril, an angiotensin-converting enzyme (ACE) inhibitor, with outcomes in patients with heart failure and reduced ejection fraction (HFrEF) in the Studies of Left Ventricular Dysfunction (SOLVD) Treatment trial. Methods and results Two thousand five hundred and sixty-nine patients with HFrEF (ejection fraction ≤35%) were randomized to below-target (5–10 mg/day) dose placebo (n = 1284) or enalapril (n = 1285). One month post-randomization, blind up-titration to target (20 mg/day) dose was attempted for both study drugs in 2458 patients. Among the 1444 patients who achieved dose up-titration (placebo, n = 748; enalapril, n = 696; mean dose for both groups, 20.0 mg/day), target dose enalapril (vs. target dose placebo) was associated with a 9% absolute lower risk of the combined endpoint of heart failure hospitalization or all-cause mortality [adjusted hazard ratio (HR) 0.70; 95% confidence interval (CI) 0.60–0.81; P < 0.001] during 4 years of follow-up. Among the 1014 patients who could not achieve target dose (placebo, n = 486; enalapril, n = 528; mean dose for both groups, 8.8 mg/day), below-target dose enalapril (vs. below-target dose placebo) was associated with a 12% absolute lower risk of the combined endpoint of heart failure hospitalization or all-cause mortality (adjusted HR 0.68; 95% CI 0.57–0.81; P < 0.001). Among the 1224 patients receiving enalapril, target (vs. below-target) dose had no association with the combined endpoint of heart failure hospitalization or all-cause mortality (adjusted HR 1.04; 95% CI 0.87–1.23; P = 0.695). Conclusion In patients with HFrEF, the clinical benefits of ACE inhibitors appear to be similar at both below-target and target doses.

Heart failure is a disease of poor prognosis marked by frequent hospitalizations, premature death, and impaired quality of life. Despite advances in medical therapy for patients with heart failure and reduced ejection fraction, mortality and hospitalizations with advanced disease are still increased and the quality of life continues to be poor in this population. The advent of cardiac resynchronization therapy has led to a significant improvement in both survival and symptom management in patients with heart failure and reduced ejection fraction. Its beneficial effects in the elderly population, however, are not well-defined.

Purpose Patients who suffer from device malfunction after axial-flow left ventricular assist device (af-LVAD) implantation often require device exchange. Although af-LVAD to af-LVAD exchange is reported as a safe procedure, rate of recurrent malfunction remains high. We hypothesized that af-LVAD to centrifugal-flow LVAD (cf-LVAD) exchange is associated with lower rate of recurrent malfunction requiring repeat exchange compared to af-LVAD to af-LVAD exchange. Methods We retrospectively reviewed all patients who underwent af-LVAD implantation between 5/2011 and 3/2019 at out institution. Of these, 31 patients underwent 43 device exchanges either to af-LVAD (AE group, N = 29) or to cf-LVAD (CE group, N = 14). Results Reasons of device exchange in the AE group were pump thrombosis in 19 (66 %), infection in 1 (3 %) and others in 9 (31 %), and those in the CE group were pump thrombosis in 8 (58 %), infection in 3 (21 %) and others in 3 (21 %). There was no difference in baseline characteristics between the groups except higher rate of more than mild aortic insufficiency in the CE group (CE; 50 % vs AE; 0 %, P Conclusion Af-LVAD to cf-LVAD exchange is a safe procedure for af-LVAD patients who require device exchange, and possibly decrease recurrent device malfunction event requiring repeat device exchange.

Aims Hypokalaemia is a risk factor for ventricular arrhythmias and sudden death in ambulatory patients with chronic heart failure (HF). The objective of this study was to examine the association between hypokalaemia and outcomes in hospitalized patients with decompensated HF in whom sudden death is less common. Methods and results Of the 5881 hospitalized patients with HF, 1052 had consistent hypokalaemia (both admission and discharge serum potassium

Background In the Studies of Left Ventricular Dysfunction (SOLVD) treatment trial, similar clinical benefits were observed between starting doses of enalapril and the target dose achieved by postrandomization up-titration. In our current analysis, protecting the randomization, we examined the early effects of starting doses of enalapril. Methods There were 2569 patients with mild-to-moderate chronic heart failure with reduced ejection fraction (ejection fraction ≤ 35%) randomized to receive starting doses (5-10 mg/day) of placebo (n = 1284) or enalapril (n = 1285). At day 14, both study drugs were blindly up-titrated to the target dose (20 mg/day). Overall, 96% (2458/2569) of the patients returned for dose up-titration, which was achieved in 59% (1444/2458), 48% (696/1444) of whom were in the enalapril group. Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes in the enalapril group were estimated. Results HRs (95% CIs) for all-cause mortality, heart failure hospitalization, and the combined endpoint of heart failure hospitalization or all-cause mortality at 14 days after randomization were 0.80 (0.32-2.03), 0.63 (0.35-1.12), and 0.65 (0.39-1.06), respectively. Corresponding HRs (95% CIs) at 30 days were 0.82 (0.41-1.67), 0.43 (0.27-0.68), and 0.43 (0.27-0.68), respectively. The magnitude of these early effects of starting doses of enalapril is similar to its previously reported long-term effects at the target dose. Conclusion These data suggest that in stable ambulatory patients with heart failure with reduced ejection fraction, the magnitude of the early effect of starting doses of enalapril is similar to that observed during longer-term therapy with the target doses of the drug.

Background Heart failure is a leading cause for hospital readmission. Digoxin use may lower this risk in patients with heart failure with reduced ejection fraction (HFrEF), but data on contemporary patients receiving other evidence-based therapies are lacking. Methods Of the 11,900 patients with HFrEF (ejection fraction ≤ 45%) in Medicare-linked OPTIMIZE-HF, 8401 were not on digoxin, of whom 1571 received discharge prescriptions for digoxin. We matched 1531 of these patients with 1531 not receiving digoxin by propensity scores for digoxin use. The matched cohort (n = 3062; mean age, 76 years; 44% women; 14% African American) was balanced on 52 baseline characteristics. We assembled a second matched cohort of 2850 patients after excluding those with estimated glomerular filtration rate Results Among the 3062 matched patients, digoxin use was associated with a significantly lower risk of heart failure readmission at 30 days (HR, 0.74; 95% CI, 0.59-0.93), 1 year (HR, 0.81; 95% CI, 0.72-0.92), and 6 years (HR, 0.90; 95% CI 0.81-0.99). The association with all-cause readmission was significant at 1 and 6 years but not 30 days. There was no association with mortality. Similar associations were observed among the 2850 matched patients without bradycardia or renal insufficiency. Conclusions Among hospitalized older patients with HFrEF receiving contemporary treatments for heart failure, digoxin use is associated with a lower risk of hospital readmission but not all-cause mortality.

National guidelines recommend that systolic blood pressure (SBP) in patients with heart failure with reduced ejection fraction (HFrEF) and hypertension be maintained below 130 mm Hg.This study sought to determine associations of SBP 130 mm Hg with outcomes in patients with HFrEF.Of the 25,345 patients in the Medicare-linked OPTIMIZE-HF registry, 10,535 had an ejection fraction (EF) ≤40%. Of these, 5,615 had stable SBP (≤20 mm Hg admission to discharge variation), and 3,805 (68%) had a discharge SBP 130 mm Hg. Propensity scores for SBP 130 mm Hg, estimated for each of the 5,615 patients, were used to assemble a matched cohort of 1,189 pairs of patients with SBP 130 versus ≥130 mm Hg, balanced on 58 baseline characteristics (mean age 76 years; mean EF 28%, 45% women, 13% African American). This process was repeated in 3,946 patients, after excluding 1,669 patients (30% of 5,615) with a discharge SBP 110 mm Hg and assembled a second matched balanced cohort of 1,099 pairs of patients with SBP 110 to 129 mm Hg versus ≥130 mm Hg.Thirty-day all-cause mortality occurred in 7% and 4% of matched patients with SBP 130 mm Hg versus ≥130 mm Hg, respectively (hazard ratio [HR]: 1.76; 95% confidence interval [CI]: 1.24 to 2.48; p = 0.001). HRs (95% CIs) for all-cause mortality, all-cause readmission, and HF readmission at 1 year, associated with SBP 130 mm Hg, were 1.32 (1.15 to 1.53; p 0.001), 1.11 (1.01 to 1.23; p = 0.030), and 1.24 (1.09 to 1.42; p = 0.001), respectively. HRs (95% CIs) for 30-day and 1-year all-cause mortality associated with SBP 110 to 129 mm Hg (vs. ≥130 mm Hg) were 1.50 (1.03 to 2.19; p = 0.035), and 1.19 (1.02 to 1.39; p = 0.029), respectively.Among hospitalized older patients with HFrEF, SBP 130 mm Hg is associated with poor outcomes. This association persisted when the analyses were repeated after excluding patients with SBP 110 mm Hg. There is an urgent need for randomized controlled trials to evaluate optimal SBP reduction goals in patients with HFrEF.

Purpose To investigate the safety and efficacy of argatroban in preventing thrombotic complications in patients with suspected heparin-induced thrombocytopenia (HIT) treated with axillary flow left ventricular assist device (Impella). Methods We performed a retrospective observational case-series of patients who were supported on Impella and anticoagulated with argatroban due to suspected HIT. The electronic medical record was reviewed for safety events including hemorrhagic or embolic stroke, bleeding and Impella motor thrombosis. Results We identified six patients who met inclusion criteria. Three patients were definitively diagnosed with HIT. In each case argatroban was used as the Impella purge solution and intravenous argatroban was administered as needed to maintain a PTT target of 50-80 seconds. The purge solution was formulated as argatroban 25mg in 500mL of dextrose 5% water. The Impella controller was programmed to a heparin purge fluid concentration of “0 IU/ml”. Only one patient had a bleeding event; this involved minor bleeding from the endotracheal tube. Prior to initiation of argatroban; the PTT in this patient was elevated secondary to hepatic dysfunction which likely predisposed to bleeding. No patient developed a hemorrhagic or embolic stroke, or Impella motor thrombosis. Conclusion In this case series, the use of argatroban was a safe and effective alternative to heparin in patients with suspected HIT supported with Impella. Only one patient had a bleeding event that was attributed to underlying coagulopathy secondary to hepatic dysfunction and not from argatroban. In all patients argatroban was effective in preventing Impella motor thrombosis. Currently, the Impella console can only be programmed to administer heparinized purge solution which is a barrier to the use of alternative anticoagulants. Further investigation is needed to support the use of alternative anticoagulants in patients treated with Impella.

Purpose Despite the approval of LVADs as destination therapy (DT) nearly 2 decades ago, significant knowledge gaps remain regarding the characteristics and outcomes of AA patients (pts) who receive LVAD therapy as DT. The present analysis sought to assess the characteristics and outcomes of DT LVAD AA pts. Methods Single center retrospective review of DT LVAD pts from 1/1/2009 to 12/31/2019 was performed. We compared clinical characteristics of AAs to non-AAs. Survival and hemocompatibility-related adverse event (HRAE) rates for AA pts were determined. Uni- and multivariate predictors of mortality were identified. Results 256 pts underwent DT LVAD implantation, of which 180 (70%) were AA. 63 pts received a HMII, 54 HVAD, and 63 HM3. Compared to non-AAs, AA pts were younger (AA: 57 ± 12 vs non-AA: 67 ± 9), more likely to be female (33% vs 16%) have HTN (71% vs 57%), had a higher BMI (mean BMI 30 ± 8 vs 26 ± 5), a non-ischemic cardiomyopathy (76% vs 33%), and a history of stroke/TIA (19% vs 8%). There were no significant differences between the 2 groups in terms of INTERMACS profile. Post-operatively, the AA cohort required more days of vasopressor support (9.5 ± 14 vs. 6.0 ± 6) and had a higher postoperative length of stay (32.9 ± 21.0 vs. 26.2 ± 21.9 days). Among AAs, GI bleeding was the most common HRAE (44% of patients with events per patient year, EPPY 0.55) followed by stroke (22%, EPPY 0.13) and pump thrombosis (16%, EPPY 0.13). The HM3 was associated with lowest HRAE rates (EPPY) amongst the 3 devices (GIB 0.40, stroke 0.07, and no pump thrombosis events). Overall survival among AA DT pts was 81% and 69% at 1-year and 2-years. 5-year survival was 41%. On univariate analysis, history of prior sternotomy (HR 1.93, 95% CI 1.03-3.59, p=0.04) and total bilirubin (HR 1.21, 95% CI 1.04-1.40, p=0.01) were predictors of AA mortality while INTERMACS profile ≥3 (HR 0.67, 95% CI 0.49-0.93, p=0.02) was associated with improved survival. Total bilirubin was the only independent predictor of mortality in multivariate analysis (HR 1.18, 95% CI 1.0-1.4, p=0.05). Conclusion AA DT LVAD pts experienced excellent 1- and 2-year survival comparable to those demonstrated in large clinical studies. HM3 implantation was associated with lower rates of GIB, pump thrombosis, and stroke. Future research focused on barriers to LVAD therapy and the quality of life of AA LVAD pts is warranted.

Purpose Continuous infusion of inotropes is increasingly used in patients with end-stage heart failure who are being discharged from the hospital. However, Dobutamine and Milrinone are both known to be arrhythmogenic agents. Because Milrinone does not act through the beta-adrenergic system, it may allow for the cautious addition of beta-blockers (BB). We therefore sought to compare the impact of BB use is these patients on ventricular arrhythmias. Methods We retrospectively reviewed all patients who were discharged from our Institution on inotropes (used as a bridge to durable LVAD or transplant, as a bridge to recovery, or as a palliative measure). The cohort was stratified into 2 groups based on whether BB were added to the medical regimen. We compared the incidence of ventricular arrhythmias and ICD device therapy (defined as shock or anti-tachycardia pacing) between the 2 groups. Results Between 2010 and 2017, 349 patients were discharged on inotropes. Mean age was 61+14 years, 74% were men and 64% were African American. Most patients (330) were treated with Milrinone. BB were used in 195 (56%) of patients, whereas 154 (44%) did not receive these meds. There were no significant differences between the 2 groups in baseline socio-demographics, etiology of cardiomyopathy, CV comorbidities, or invasive hemodynamics. Patients on BB were more likely to receive an LVAD/transplant (49% vs. 41%) or be weaned off inotropes (12% vs. 4%), and less likely to transition to hospice care/death (37% vs 53%). Patients on BB were more likely to receive ACEI/ARB than those who were not on BB (67% vs. 47%, p Conclusion In heart failure patients who are discharged on inotropes, the use of BB appears to be associated with a lower incidence of sustained ventricular arrhythmias, ICD shocks or anti-tachycardia pacing. Prospective studies are warranted to confirm these findings.

Cobalt toxicity is a rare cause of infiltrative cardiomyopathy. We describe a case of cobalt-induced cardiomyopathy that progressed to end stage heart failure requiring orthotopic heart transplantation. A 67 year old woman with history of bilateral cobalt-chromium hip replacements presented with dyspnea of 3 weeks duration. She was tachycardic and hypotensive, with elevated NT- proBNP. Electrocardiogram demonstrated sinus tachycardia, low voltage and right bundle branch block. Transthoracic echocardiogram revealed left ventricular ejection fraction of 20-25% with global hypokinesis and a moderate circumferential pericardial effusion. Left and right heart catheterization showed normal coronaries, elevated filling pressures and low cardiac index. Dobutamine infusion was initiated for management of cardiogenic shock. Cardiac magnetic resonance imaging (MRI) illustrated diffuse late gadolinium enhancement concerning for infiltrative cardiomyopathy. Extensive non-ischemic and rheumatologic workup was negative. Cobalt and chromium levels were significantly elevated at 121 mcg/L (Nl

Purpose A thoracotomy approach for left ventricular assist device implantation is theoretically beneficial in patients who had previous sternotomy. The aim of this study is to investigate short-term outcomes of a thoracotomy approach versus a re-do sternotomy approach for left ventricular assist device implantation in patients with previous sternotomy. Methods We retrospectively reviewed 227 patients who underwent left ventricular assist device (HeartWare, HVAD) implantation between 7/2011 and 1/2019. Of these, 52 had a previous sternotomy. Twenty-eight patients were excluded because they had an extracorporeal ventricular assist device, cardiac surgery during the same hospitalization, concomitant procedures or an alternative outflow graft anastomosis at the time of the implantation. The study cohort was divided in two groups based on incision approach: a left anterior thoracotomy approach (LAT group, N=14) and a re-do sternotomy approach (RS group, N=10). Results Previous cardiac surgeries of the cohort were coronary artery bypass grafting (CABG) in 16 patients, aortic valve replacement (AVR) in 1, mitral valve (MV) replacement in 1, MV repair in 1, CABG + AVR in 1, CABG + MV repair in 1, atrial septal defect closure in 2, and heart transplant in 1. There was no difference in baseline characteristics between the groups. Median cardiopulmonary bypass time was similar, though median operative time in the LAT group was longer than that in the RS group (LAT; 267 mins vs RS; 235 mins). There was no statistical difference in postoperative short-term outcomes between the groups, except the LAT group required less postoperative red blood cell transfusion compared to the RS group (LAT; 57 % vs RS; 100 %, P = 0.024). Conclusion A thoracotomy approach was feasible alternative in patients with previous cardiac surgery and associated with less blood transfusion requirement compared with a re-do sternotomy approach.

Purpose Excellent outcomes following HM3 LVAD implantation have been reported in the setting of a large multicenter randomized controlled trial. Real world experience reports with this device are still limited. We sought to review our experience with this fully magnetically levitated LVAD. Methods The first 125 consecutive patients who received a HM3 LVAD at our institution from October 1, 2015 to August 30, 2019 were analyzed. Pump exchange procedures were excluded. We investigated clinical outcomes including survival and the development of postoperative complications. Results All devices were implanted via median sternotomy. Mean patient age was 57.5 ± 11 years, 72 % were males and 74% African-Americans. Idiopathic dilated cardiomyopathy was the most common diagnosis (73%). 67 % of the patients were INTERMACS profiles 1 or 2. 19 % of devices were implanted as bridge to transplant and 59% as destination therapy. Mean body-mass index at the time of implant was 30.5 ± 8 Kg/m2. Mean creatinine level was 1.29 ± 0.4 mg/dl and mean bilirubin was 1.45 ± 1.6 mg/dl. The mean length of stay during index admission for LVAD was 30 ± 17 days and the mean follow-up time was 411 ± 34 days. The rate of complications measured as EPPY was 0.42 for GI bleeding, 0.03 for ischemic stroke, 0.01 for hemorrhagic stroke, 0 for clinically suspected pump thrombosis or confirmed pump thrombosis, 0.22 for LVAD related infection, 0.16 for other systemic infection and 0.59 for acute heart failure. Survival was estimated at 96%, 91%, 88%, 81% and 74% at 30-day, 90-day, 1-year, 2-year, and overall 3-year follow-up, respectively (Figure). Conclusion In this single center, real world experience, HeartMate 3 implantation was associated with excellent survival comparable to those demonstrated in a recent clinical trial. The incidence of complications was also low, including no episodes of suspected or confirmed pump thrombosis.

Purpose Outcomes of patients with small body size following HM3 LVAD implantation have not been well characterized. We sought to compare preoperative characteristics and clinical outcomes among patients stratified by body surface area. Methods Patients who received a HeartMate 3 LVAD at our institution between October 1, 2015 and June 30, 2019 were analyzed. Patients who received a HM3 LVAD as pump exchange were excluded. The cohort was divided in 4 groups: BSA ≤1.8 m2 (group 1), BSA >1.8 - ≤2.0 m2 (group 2), BSA >2.0 - ≤2.2 m2 (group 3) and BSA >2.2 (group 4). Results One hundred and nineteen patients were included in this analysis. Preoperative characteristics and postoperative results of each group are shown in Table 1. Group 1 patients were older and mostly females. A history of diabetes was less common in this group. Mean postoperative length of stay was similar between groups. Pump speed at the time of discharge was lower in group 1 patients. Mean follow-up was similar between groups. Mean days out of the hospital after discharge did not differ among the groups. One-year survival was 93% for group 1, 85% for group 2, 86% for group 3 and 84% for group 4 (p=0.69). Kaplan Meier survival curves are shown in Figure 1 (log rank: 0.692). Conclusion Outcomes following HM3 LVAD implantation were comparable between patients with small body surface area and patients with larger body size. Small body size should not be an exclusion criteria for HM3 LVAD implantation in patients with advanced heart failure who are otherwise candidates for durable mechanical support.