There is waning interest amongst cardiology trainees in pursuing an Advanced Heart Failure/Transplant Cardiology (AHFTC) fellowship as evidenced by fewer applicants in the NRMP match to this specialty. This trend has generated considerable attention across the heart failure (HF) community. In response, the Heart Failure Society of America convened the AHFTC Fellowship Task Force with a charge to develop strategies to increase the value proposition of an AHFTC fellowship. Subsequently, the HFSA sponsored the AHFTC Fellowship Consensus Conference April 26 - 27, 2023. Prior to the conference, interviews of 44 expert stakeholders diverse across geography, site of practice (traditional academic medical center or other centers), specialty/area of expertise, sex, and stage of career were conducted virtually. Based on these interviews, potential solutions to address the declining interest in AHFTC fellowship were categorized into five themes: 1. Alternative training pathways; 2. Regulatory and compensation; 3. Educational improvements; 4. Exposure and marketing for pipeline development; and 5. Quality of life and mental health. These themes provided structure to the deliberations of the AHFTC Fellowship Consensus Conference. The recommendations from the Consensus Conference were subsequently presented to the HFSA Board of Directors (BOD) to inform strategic plans and interventions. The HFSA BOD later reviewed and approved submission of this document. The purpose of this communication is to provide the HF community with an update summarizing the processes employed and concepts which emerged from the work of the HFSA AHFTC Fellowship Task Force and Consensus Conference.

Non-US citizens/non-US residents (NCNR) are a unique and growing population. Patterns of heart donation and heart transplantation (HT) within this subgroup have not been described fully. The purpose of this study was to evaluate the use of organs from NCNR donors and the characteristics and outcomes of NCNR HT recipients. All adult donors whose hearts were recovered for HT and all primary adult HT recipients from 2013 to 2020 were identified using the United Network for Organ Sharing. Donors and recipients were categorized as citizens, residents, or NCNR. NCNR were further categorized by reason for travel to the United States. Outcomes included mortality, infection, and rejection at 1-year after transplantation. NCNR accounted for 0.4% (n = 77) of heart donors. Most NCNR donors identified as Hispanic (61%), were predominately recovered from the South and Southwest United States, and were less likely to express written documentation to be a donor compared with citizens and residents. NCNR accounted for 0.7% (n = 147) of all HT recipients. The majority identified as non-Hispanic White individuals (57.1%). Compared with citizens and residents, NCNR recipients seemed to be sicker, as evidenced by higher intra-aortic balloon pump use before HT and higher priority United Network for Organ Sharing status. Of NCNR recipients, 63% traveled to the United States for HT, predominately from Kuwait (29.9%) and Saudi Arabia (20%). At 1-year after transplant, there were no differences in mortality, infection, or rejection between the groups. A growing subgroup of NCNR travel from countries with low HT rates to the United States for HT. This finding highlights the need for strategies to improve equitable access to HT domestically and abroad.

Consensus recommendations for cardiogenic shock (CS) advise transfer of patients in need of advanced options beyond the capability of 'spoke' centers to tertiary/ 'hub' centers with higher capabilities. However, outcomes associated with such transfers are largely unknown, beyond those reported in individual health networks. To analyze a contemporary, multicenter CS cohort with an aim to compare characteristics and outcomes of patients between transfer (between spoke and hub center) and non-transfer cohorts (those primarily admitted to a hub center), for both acute myocardial infarction (AMI-CS) and heart failure related (HF-CS) shock. We also aim to identify clinical characteristics of the transfer cohort that are associated with in-hospital mortality. The Cardiogenic Shock Working Group (CSWG) registry is a national, multicenter, prospective registry including high volume (mostly hub) CS centers. Fifteen U.S. sites contributed data for this analysis from 2016-2020. Of 1890 consecutive CS patients enrolled into the CSWG registry, 1028 (54.4%) patients were transferred. Of these, 528 (58.1%) had heart failure related CS (HF-CS) and 381 (41.9%) had CS related to acute myocardial infarction (AMI-CS). Upon arrival to the CSWG site, transfer patients were more likely to be in SCAI stage C and D, when compared to non-transfer patients. Transfer patients had higher mortality (37% vs. 29%, <0.001) than non-transfer patients with the differences primarily driven by the HF-CS cohort. Logistic regression identified increasing age, mechanical ventilation, renal replacement therapy, and higher number of vasoactive drugs prior to, or within 24 hours after CSWG site transfer as independent predictors of mortality among HF-CS patients. Conversely, pulmonary artery catheter use prior to transfer, or within 24 hours of arrival was associated with decreased mortality. Among transfer AMI-CS patients BMI>28 kg/m2, worsening renal failure, lactate>3 mg/dl and increasing number of vasoactive drugs were associated with increased mortality. More than half of CS patients managed at high volume CS centers were transferred from another hospital. Although transfer patients had higher mortality than those who were primarily admitted to hub centers, outcomes and their predictors varied significantly when classified by HF-CS versus AMI-CS.

To assess tissue Doppler-derived mitral annular isovolumic contraction velocity (ICV) after starting sacubitril/valsartan (sac/val) for the treatment of heart failure with reduced ejection fraction (HFrEF; left ventricular [LV] EF <40%). ICV may inform load-independent systolic function; combining ICV and LVEF may improve assessment of LV contractility. Among 651 HFrEF participants treated with sac/val, echocardiograms were performed at baseline, 6, and 12 months. Pre-treatment median ICV and LVEF were used for classification to predict LV reverse remodeling, health status using the Kansas City Cardiomyopathy Questionnaire, and biomarker concentrations. The mean age was 64.6±12.4 years, and 28% were women, baseline LVEF: 28.9±6.9%. Compared to baseline, median ICV increased post sac/val therapy (4.6 [3.5, 6.1] vs. 4.9 [3.6, 6.4], p=0.005). ICV added value to separate and combined models of biomarkers, clinical, and echocardiographic variables for prediction of post-therapy EF recovery. Classification using baseline ICV/EF yielded relatively equal numbers in 4 groups based on low/high ICV or LVEF. Most deleterious results for remodeling, health status, and biomarkers were found in low-ICV/low-EF patients, while high ICV/high EF had the best profiles; other groups were intermediate. Significant shifts towards better ICV/EF profiles were noted post sac/val treatment compared to baseline, with doubling of high-ICV/high-EF [241(60%) vs. 123(31%)] and 78% reduction of low-ICV/low-EF [28(7%) vs. 125(32%)]. In HFrEF, ICV adds to the profiling of systolic function and represents an independent predictor of reverse cardiac remodeling after treatment with sac/val. ICV changes may be used for assessment of treatment response.

STRONG-HF demonstrated the safety and efficacy of rapid up-titration of guideline-directed medical therapy (GDMT) with high intensity care (HIC) compared to usual care in patients hospitalized for acute heart failure (HF). In the HIC group, the following safety indicators were used to guide up-titration: estimated glomerular filtration rate [eGFR] <30ml/min/1.73m2, serum potassium >5.0 mmol/L, systolic blood pressure (SBP) <95mmHg, heart rate <55bpm, NT-proBNP concentration >10% higher than pre-discharge values. We examined the impact of protocol-specified safety indicators on achieved dose of GDMT and clinical outcomes. Three-hundred-thirteen of the 542 patients in the HIC arm (57.7%) met at least one safety indicator at any follow-up visit 1 to 6 weeks after discharge. As compared to those without, patients meeting at least one safety indicator had more severe HF symptoms, lower SBP and higher heart rate at baseline and achieved a lower average percentage of GDMT optimal doses (mean difference vs the HIC arm patients not reaching any safety indicator, -11.0% [95% CI -13.6 to -8.4%], P<0.001). The primary endpoint of 180-day all-cause death or HF re-admission occurred in 15.0% of patients with any safety indicator versus 14.2% of those without (adjusted hazard ratio [HR] 0.84, 95% CI 0.48 to 1.46, P=0.540). None of each safety indicator, considered alone, was significantly associated with the primary endpoint, but SBP < 95mmHg was associated with a trend towards increased 180 days all-cause mortality (adjusted HR = 2.68 [0.94 to 7.64]; P = 0.065) and eGFR drop to < 30ml/min/1.73m2 with more HF readmissions (adjusted HR 3.60 [1.22 to 10.60]; p = 0.0203). The occurrence of a safety indicator was associated with a smaller 90-day improvement in EQ-5D VAS (adjusted mean difference -3.32 points, 95% CI -5.97 to -0.66, P=0.015). Among patients with acute HF enrolled in STRONG-HF in the HIC arm, the occurrence of any safety indicator was associated with the administration of slightly lower GDMT doses and less improvement in quality of life but with no significant increase in the primary outcome of 180-day HF readmission or death when appropriately addressed according to the study protocol.

Study participants (n = 272) completed 12 Patient-Reported Outcomes Measurement Information System (PROMIS) physical, mental and social health measures (questionnaires) prior to implantation of a left ventricular assist device (LVAD) and again at 3 and 6 months postimplant. All but 1 PROMIS measure demonstrated significant improvement from pre-implant to 3 months; there was little change between 3 and 6 months. Because PROMIS measures were developed in the general population, patients with an LVAD, their caregivers and their clinicians can interpret the meaning of PROMIS scores in relation to the general population, helping them to monitor a return to normalcy in everyday life.

The presence of ischemic heart disease impacts prognosis in patients affected by heart failure and reduced ejection fraction (HFrEF). It is not well known how the extent of vascular disease impacts prognoses and responses to therapy in this setting. In this post hoc analysis of the EMPEROR-Reduced trial, outcomes and the effects of empagliflozin, were assessed in study participants according to the extent (none vs mono1 vs poly [≥ 2] vascular bed) of vascular disease. Vascular disease was defined as investigator-reported coronary artery disease (CAD), peripheral artery disease (PAD) and cerebrovascular disease at baseline. Cox proportional-hazards models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). Incidence rates are presented per 100 person-years (py) of follow-up. Of the 3730 study participants enrolled, 1324 (35.5%) had no vascular disease, 1879 (50.4%) had monovascular disease, and 527 (14.1%) had polyvascular disease. Participants with polyvascular disease tended to be older and male and to have had histories of hypertension, diabetes and smoking. In the placebo arm, a significantly higher risk for cardiovascular death existed in those with polyvascular disease (HR 1.57, 95% CI1.02, 2.44, compared to those with no vascular disease). In adjusted analysis, the benefit of empagliflozin in cardiovascular death or hospitalization due to HF, HF hospitalization, cardiovascular death, renal composite endpoint, estimated glomerular filtration slope changes, and health status scores were seen across the 3 groups (interaction P > 0.05 for all) but were attenuated in those with polyvascular disease. Adverse events were higher in those with polyvascular disease, but no major differences were noted between empagliflozin or placebo assignment in the 3 groups. In patients with HFrEF, the extent of vascular disease is associated with the risk for adverse cardiovascular outcomes. Empagliflozin offers cardiovascular and renal benefits in HFrEF across the extent of vascular disease, but this benefit is attenuated in those with polyvascular disease.

The current Impella cardiopulmonary (CP) pump, used for mechanical circulatory support in patients with cardiogenic shock (CS), cannot assess native cardiac output (CO) and left ventricular (LV) volumes. These data are valuable in facilitating device management and weaning. Admittance technology allows for accurate assessment of cardiac chamber volumes. This study tested the ability to engineer admittance electrodes onto an existing Impella CP pump to assess total and native CO as well as LV chamber volumes in an instantaneous manner. Impella CP pumps were fitted with 4 admittance electrodes and were placed in the LVs of adult swine (n = 9) that were subjected to 3 different hemodynamic conditions, including Impella CP speed adjustments, administration of escalating doses of dobutamine and microsphere injections into the left main artery to result in cardiac injury. CO, according to admittance electrodes, was calculated from LV volumes and heart rate. In addition, CO was calculated in each instance via thermodilution, continuous CO measurement, the Fick principle, and aortic velocity-time integral by means of echocardiography. Modified Impella CP pumps were placed in swine LVs successfully. CO, as determined by admittance electrodes, was similar by trend to other methods of CO assessment. It was corrected for pump speed to calculate native CO, and calculated LV chamber volumes trended as expected in each experimental protocol. We report, for the first time, that an Impella CP pump can be fitted with admittance electrodes and used to determine total and native CO in various hemodynamic situations. Transvalvular mechanical circulatory support devices such as the Impella CP do not have the ability to provide real-time information on native cardiac output (CO) and left ventricular (LV) volumes. This information is critical in device management and in weaning in patients with cardiogenic shock. We demonstrate, for the first time, that Impella CP pumps coupled with admittance electrodes are able to determine native CO and LV chamber volumes in multiple hemodynamic situations such as Impella pump speed adjustments, escalating dobutamine administration and cardiac injury from microsphere injection.