Biventricular Heart Failure Research Articles

Predictors of hospitalizations for heart failure decompensation in patients with comorbid occupational chronic obstructive pulmonary disease

Abstract Background Heart failure decompensation requiring hospitalization is an important event, associated with mortality and investigating its predictors is topical problem. Chronic obstructive pulmonary disease (COPD) is a common comorbidity for heart failure. Both conditions share common molecular mechanisms such as systemic inflammation. COPD is heterogeneous and subpopulations with different inflammation patterns may interact with heart failure in different manner. Airway inflammation in occupational COPD may differs from COPD in tobacco smokers. Additionally cardiotoxicity of industrial chemicals influence heart failure features. Despite this biological plausibility, heart failure and occupational COPD comorbidity is not studied enough. Purpose To reveal predictors of hospitalizations for heart failure decompensation in patients with heart failure and occupational COPD comorbidity. Methods Occupational COPD patients (n=115) were investigated in a prospective cohort observational study. Comparison group – 115 tobacco smokers with COPD. Control group – 115 healthy persons. Controls were selected by propensity score matching, covariates were COPD duration, age and gender. Then COPD groups were stratified according to heart failure. Working conditions, echocardiography, spirometry, pulsoxymetry, 6-mitute walking test were done. Molecular markers of tissue damage – chemokine ligand 18 (CCL 18), lactate dehydrogenase, cardiac troponin T, N-terminal pro-B-type natriuretic peptide (NT pro-BNP), protein S100 beta, von Willebrand factor were measured in serum by ELISA. Follow up after initial assessment was 12 month. Predictors were determined by Cox proportional hazards regression with ROC analysis. Results Heart failure rate in occupational COPD patients were higher – 54.8% versus 36.5% in tobacco smokers with COPD, p<0.05. Heart failure with preserved ejection fraction was predominant – 40.9%. Prevalence of biventricular heart failure was 38.3%, isolated right heart failure – 13%, left heart failure – 2.6%. Cumulative hospitalization rate in occupational COPD with heart failure group was higher than in comparison group, 17.5% and 9.5% respectively, p=0.01. In Cox proportional hazards regression model predictors of hospitalizations for heart failure decompensation during 12 months in this group were length of service (HR 1.22, 95% CI: 1.03–2.5), aromatic hydrocarbons concentration at workplaces air (HR 1.4, 95% CI: 1.15–1.96), serum protein S100 beta (HR 1.10, 95% CI: 1.02–1.87), SaO2 (HR 1.2, 95% CI: 1.06–2.13). Area under the ROC curve was 0.82. Conclusion Length of service, aromatic hydrocarbons concentration at workplaces air, serum protein S100 beta, SaO2 are considered to be independent risk factors of heart failure decompensation required hospitalization in patients with heart failure and occupational COPD comorbidity. Funding Acknowledgement Type of funding source: None

Striking Similarities of Multisystem Inflammatory Syndrome in Children and a Myocarditis-Like Syndrome in Adults: Overlapping Manifestations of COVID-19.

Striking Similarities of Multisystem Inflammatory Syndrome in Children and a Myocarditis-Like Syndrome in Adults: Overlapping Manifestations of COVID-19.

Abstract 312: The Tricuspid Valve Also Maladapts: Evidence From Sheep With Functional Tricuspid Regurgitation

The objective of this work was to determine whether tricuspid valve leaflets maladapt to functional regurgitation as they do in the mitral valve. If they did, pharmacological control of the underlying mechanisms could open opportunities to support tricuspid valve surgery and improve currently poor outcomes. To this end, we used a biventricular heart failure model to induce functional tricuspid valve regurgitation in sheep. We sacrificed animals once they showed signs of heart failure (with in 2-3 weeks). In those animals (and controls), we measured tricuspid anterior leaflet area and thickness, collagen content via ELISAs, tissue stiffness via mechanical testing, and cellular changes via immunohistochemistry. We found a statistically significant increase with disease in leaflet area (p=0.004), thickness (p=0.037), collagen content (p=0.001), circumferential leaflet stiffness (p=0.001), and SMA (p=0.030), Figure 1. Our findings imply that in approximately 2-3 weeks of biventricular heart failure and associated functional tricuspid regurgitation, tricuspid valve leaflets underwent substantial remodeling. Specifically, it appears that activation of valvular interstitial cells increased collagen syntheses resulting in leaflet growth, thickening, and stiffening. No other previous study has demonstrated tissue maladaptation on all functional scales in the tricuspid valve. Our work is relevant as it implies that pharmacological control of this maladaptive response could allow for the promotion of the positive effects (e.g., area increase) while suppressing negative effects (e.g., fibrosis).

Autoregulation of Pulsatile Bioprosthetic Total Artificial Heart is Involved in Endothelial Homeostasis Preservation.

Pulsatile Carmat bioprosthetic total artificial heart (C-TAH) is designed to be implanted in patients with biventricular end-stage heart failure. Since flow variation might contribute to endothelial dysfunction, we explored circulating endothelial biomarkers after C-TAH implantation in seven patients and compared the manual and autoregulated mode. Markers of endothelial dysfunction and regeneration were compared before and during a 6- to 9-month follow-up after implantation. The follow-up was divided into three periods (< 3, 3-6, and > 6 months) and used to estimate the temporal trends during the study period. A linear mixed model was used to analyze repeated measures and association between tested parameters according to the mode of C-TAH and the time. Relevance of soluble endoglin (sEndoglin) level increase has been tested on differentiation and migration potential of human vasculogenic progenitor cells (endothelial colony forming cells [ECFCs]). Normal sEndoglin and soluble endothelial protein C receptor (sEPCR) levels were found in patients after implantation with autoregulated C-TAH, whereas they significantly increased in the manual mode, as compared with pretransplant values (p = 0.005 and 0.001, respectively). In the autoregulated mode, a significant increase in the mobilization of cytokine stromal cell-derived factor 1 was found (p = 0.03). After adjustment on the mode of C-TAH, creatinine or C-reactive protein level, sEndoglin, and sEPCR, were found significantly associated with plasma total protein levels. Moreover, a significant decrease in pseudotubes formation and migration ability was observed in vitro in ECFCs receiving sEndoglin activation. Our combined analysis of endothelial biomarkers confirms the favorable impact of blood flow variation achieved with autoregulation in patients implanted with the bioprosthetic total artificial heart.

Hospitalizations and Outcomes in Patients Implanted with the Total Artificial Heart and Discharged with a Portable Driver.

Hospitalizations and Outcomes in Patients Implanted with the Total Artificial Heart and Discharged with a Portable Driver.

Abstract 329: Cholecystalgia: an Atypical Presenting Symptom of Congestive Heart Failure

Acute acalculous cholecystitis is defined as acute inflammatory disease of the gallbladder without evidence of gallstones or cystic duct obstruction. Imaging studies typically show a distended acalculous gallbladder with thickened walls. Heart failure is well known to cause congestive hepatopathy and can be associated with isolated gallbladder edema which is often difficult to differentiate from acalculous cholecystitis. We present a case of cholecystalgia secondary to isolated gallbladder edema without hepatic congestion in a patient with non-ischemic cardiomyopathy mimicking the presentation of acalculous cholecystitis. A 46-year-old female with a past medical history of recently diagnosed non-ischemic cardiomyopathy during a prior hospitalization. Echocardiogram showed biventricular heart failure with EF of 15 to 20% with severe left and right ventricular dilatation and global hypokinesis. Left heart catherization showed no angiographic evidence of coronary artery disease and right heart catheterization demonstrated pulmonary hypertension secondary to left heart disease. She left against medical advice and was non-compliant with her medications. Approximately one month later, she presented with shortness of breath and orthopnea. On physical examination, jugular venous distention, S3 gallop, diffuse crackles and anasarca were noted. Labs showed BNP of 12,735. Chest CT revealed cardiomegaly and diffuse interstitial edema with bilateral pleural effusions and no signs of pulmonary embolus. Metoprolol and bumetanide were initiated for management of her acutely decompensated congestive heart failure. Several days after admission, she developed severe sharp RUQ pain associated with nausea and vomiting. She was tachypneic, diaphoretic with severe tenderness in the RUQ. Abdominal ultrasound revealed no signs of congestive hepatopathy but revealed a diffuse, edematous thickening of the gallbladder wall without evidence of stones. Hepatobiliary scintigraphy revealed preserved gallbladder function with an EF of 88%. The remainder of her care was focused on optimization of the patient’s congestive heart failure with complete resolution of her symptoms. Acute decompensation of congestive heart failure can result in an increase in pulmonary or systemic venous pressure, which may result in vascular congestion. The vascular distention can lead to isolated distention of the gallbladder wall that can mimic symptoms of acalculous cholecystitis. In such patient’s cholecystectomy or percutaneous cholecystostomy is not warranted. Radiographic evidence and symptoms usually resolve with optimization of congestive heart failure treatment. This case details the under-recognized presentation of secondary cholecystalgia in a patient with acute RUQ pain and underlying congestive heart failure.

Biventricular Support with Syncardia Total Artificial Heart: Long-Term Single-Center Experience

The SynCardia Total Artificial Heart (TAH) is a pneumatically driven assist system to provide mechanical circulatory support in patients with severe non-reversible biventricular failure, who otherwise have no mechanical support devices. The aim of our retrospective study is to assess the comorbidity and survival of patients awaiting cardiac transplant while circulatory support with TAH. We examined data related to survival, adverse events, and outcomes from patients undergoing TAH implantation between Januar 2001 and September 2019. For determination of the predictors for mortality we used multivariate analysis. Between February 2001 and September 2019, a total of 190 consecutive patients (88.9% men; mean age, 53±11.6 years,) underwent TAH implantation. Indications for TAH implantation were cardiomyopathy in 84 (44.2%), acute myocardial infarction in 50 (26.3%) and postcardiotomy biventricular heart failure in 29 (15.3%) and others (allograft rejection, myocarditis, endocarditis, congenital heart disease) in 27 patients (14.2%). The majority of patients (166/87.4%) were in INTERMACS profile 1, the remainder (24/12.7%) in INTERMACS profiles 2-3. Preoperative measures of the creatinine was 2.0±1.3 mg/dl and total bilirubin 3.0±3.8 mg/dl. The median support time was 169 days (range, 1 to 971 days). During TAH support, 32.1% of patients suffered from stroke, 30.5% from mesenteric ischemia and 24.2% from gastrointestinal bleeding. The median follow-up for survival of patients on support was 4.3 months. The 1-, 6- and 12-month survival was 71%, 42% and 35%, respectively. A total of 120 (63.2%) patients died during support. The most common causes of the death were multiorgan failure or/with sepsis. Multivariate analysis revealed that age p=0.003), underweight with BMI <18.5 kg/m² (p=0.001), higher total bilirubin (p=0.007) and preoperative IABP (p=0.013) were independent predictors for mortality during support. Sixty-nine (35.3%) were successfully bridged to transplantation after a mean support time of 311±205 days. 1-, 5- and 10-year survival was 64%, 58% and 51%, respectively. SynCardia TAH provides acceptable outcomes in critically sick patients with irreversible heart failure who are candidates for cardiac transplantation. More than one third of our TAH-patients were be successfully bridged to transplantation.

HeartMate 3 as Total Artificial Heart for the Treatment of Biventricular Heart Failure as Bridge to Transplantation

Despite maximal medican and surgical therapy, the outcomes of severe biventricular failure remain poor with mortality rates of up to 100%. The only definite therapy option for this disease is the total replacement of the heart - either by cardiac transplantation or by total artificial heart (TAH) implantation. Due to the lack of donor organs, mechanical assist devices are the most relevant option for these patients. The permanent availability of mechanical devices is especially attractive in emergency cases as well as in high-risk patients. The placement of two HeartMate 3 in the setting of a TAH is an alternative approach to pulsatile TAH implantation. We now present the worldwide first series of outcomes of this novel procedure. We performed a retrospective analysis of seven consecutive patients who underwent off-label HeartMate 3 TAH implantation after cardiectomy at two international medical institions. Data was acquired using the in-house clinical databases. Follow-up time was thirty days postoperatively. Among perioperative baseline characteristics, adverse events and survival data were collected and analyzed. The retrospective study was approved by the loca institutional ethics committee. Out of 7 patients 4 were male (57%). Primary diagnosis was dilated cardiomyopathy in four cases (4/7, 57%) Other diagnoses were stone heart syndrome, restrictive cardiomyopathy and post-partum cardiomyopathy. All patients were previously supported by ECMO. 3 patients suffered from severe ventricular thrombosis. Intraoperative mortality was 0%. One patient was successfully transplanted after 71 days on device. One patient is still on-going on the device, currently discharged and waiting for heart transplantation (POD 259). Full mobility was achieved in both patients. In all cases postoperative hemodynamic stability was successfully achieved. No device related technical complications occured. Four patients died within thirty days of support (51%; POD 10-21). Causes of death were sepsis and multi-organ failure (3/4) and stroke (1/4). It has been proven that the implantation of two HeartMate 3 VADs in the settings of a total artificial heart is a feasible concept with no technical adverse events in our patient population. In this high risk patient cohort, a reduction of 30-day-mortality from 100% to 57% was achieved.

Mechanical Circulatory Support for Biventricular Heart Failure Using Advanced Ventricular Assist Device

In patients with severe biventricular heart failure (HF) and cardiogenic shock, use of biventricular assist device (BVAD) can be a treatment of choice. We are developing an advanced ventricular assist device (AVAD) intended to serve as universal pump for left and/or right heart failure (Fig.1 A,B). The purpose of this initial in silico simulation study was to demonstrate that AVAD design can be suitable for biventricular support. The virtual mock loop (VML) was developed (MATLAB; MathWorks®) to simulate hemodynamic parameters as they surge through the BVAD-supported systolic HF cardiovascular system. The AVAD used as in BVAD configuration was in 2 speeds (3400 rpm left, 2000 rpm right) to get comparable systemic flow and pressure outputs. LVAD support was adjusted to maintain 5.0 L/min total systemic flow. For BVAD, the added RVAD support was adjusted to maintain left and right atrial pressure (LAP-RAP) at 3-5 mm Hg. The BVAD performance was maintained very well for both left ventricular (L-AVAD) and right ventricular (R-AVAD) support within specified speed range (Fig1 C,D). L- AVAD speed of 3000 - 3500 rpm provided sufficient support for the case of severe left and right systolic heart failure, assuming there was no aortic valve regurgitation. At the simulated condition, with L-AVAD support, the aortic valve remains closed and the systemic pressure has reduced pulse. A stable hemodynamics were maintained. The atrial pressure difference (LAP-RAP) resulted to be sensitive to the right pump speed, though was balanced whenever there was any positive flow through the pulmonary valve. Introduction of R-AVAD support to the L-AVAD support caused the left atrial pressure to increase resulting in increased filling of the left ventricle and a corresponding increase in aortic pulsatility. These initial in silico study demonstrated that use of the universal AVAD as BVAD supports cardiac output and arterial pressure in biventricular HF condition.

Anxiety and depression in patients with occupational chronic obstructive pulmonary disease comorbid with biventricular heart failure

Occupational chronic obstructive pulmonary disease (COPD) patients with (n=44) or without (n=52) biventricular heart failure (HF) were investigated. Comparison groups were COPD in tobacco smokers with (n=38) or without (n=65) HF. Comorbid pathology was characterized by the highest levels of anxiety and depression (HADS-A score was 7.4+0.86, HADS-D score was 7.9+0.75) associated with serum S100В.

Total artificial heart: surgical technique in the patient with normal cardiac anatomy.

Heart failure is a complex, growing problem with significant morbidity and mortality. Though heart transplantation remains the gold standard treatment for end-stage heart failure, there remains a national shortage of donor hearts. Mechanical circulatory support has provided an additional option for clinicians to support patients for the purposes of bridging patients to transplantation or to be used for destination therapy purposes. Despite generally favorable outcomes with univentricular support, in a subset of patients with biventricular heart failure, an isolated left ventricular assist device is not sufficient. Right ventricular failure has a negative impact on patient survival if not identified and treated promptly. The Total Artificial Heart (TAH) is the only Food and Drug Administration (FDA) approved artificial heart used for bridging patients to transplantation. Outcomes in patients who undergo implantation of the TAH at experienced centers have been good and reproducible.

Comparison of SynCardia total artificial heart and HeartWare HVAD biventricular support for management of biventricular heart failure: a systematic review and meta-analysis.

The aim of this study was to compare the outcomes of patients undergoing SynCardia total artificial heart (TAH) and biventricular HeartWare ventricular assist device (Bi-HVAD) support for biventricular heart failure (HF). Electronic search was performed to identify all relevant studies detailing patients who underwent biventricular assist device implantation using Bi-HVAD devices and those who underwent TAH placement for biventricular HF. Twelve studies including 512 patients in the TAH group versus 38 patients in the Bi-HVAD group were pooled for meta-analysis. Ischemic cardiac etiology was present in 32% (95% CI, 24-47) of TAH vs. 15% (95% CI, 4-44) of Bi-HVAD patients (P=0.21). There was a comparable incidence of stroke [TAH 11% (95% CI, 7-16) vs. Bi-HVAD 13% (95% CI, 2-51), P=0.86] and acute kidney injury [TAH 28% (95% CI, 2-89) vs. Bi-HVAD 27% (95% CI, 9-59), P=0.98]. Overall infection rate was 67% (95% CI, 47-82) in TAH and 36% (95% CI, 10-74) in Bi-HVAD (P=0.16). Driveline infections were comparable between the two groups [TAH 11% (95% CI, 6-19) vs. Bi-HVAD 8% (95% CI, 1-39), P=0.73] and although a higher incidence of mediastinitis was found in the Bi-HVAD group [TAH 4% (95% CI, 2-7) vs. Bi-HVAD 15% (95% CI, 4-45), P=0.07] there was no statistically significant difference between the groups. Postoperative bleeding was present in 42% (95% CI, 28-58) of TAH vs. 23% (95% CI, 8-52) of Bi-HVAD (P=0.22). Patients in the TAH group had shorter duration of support [TAH 71 days (95% CI, 15-127) vs. Bi-HVAD 167 days (95% CI, 116-217), P=0.01]. At the mean follow-up time of 120 days, (95% CI, 83-157) patients in both groups had similar overall mortality [TAH 36% (95% CI, 22-49) vs. Bi-HVAD 26% (95% CI, 6-46), P=0.44] including mortality on device support [TAH 26% (95% CI, 17-36) vs. Bi-HVAD 21% (95% CI, 4-37), P=0.55]. Discharge home on support was achieved in 6% (95% CI, 4-17%) of TAH patients vs. 73% (95% CI, 48-89%) of Bi-HVAD (P<0.01), and 68% (95% CI, 52-84) of TAH patients were transplanted vs. 61% (95% CI, 47-75) in the Bi-HVAD group (P=0.14). Patients on Bi-HVAD support were more likely to be able to be discharged home on support and had similar overall mortality to TAH, albeit with much longer duration of support.

Development of a circulatory mock loop for biventricular device testing with various heart conditions.

This study aimed to evaluate a newly designed circulatory mock loop intended to model cardiac and circulatory hemodynamics for mechanical circulatory support device testing. The mock loop was built with dedicated ports suitable for attaching assist devices in various configurations. This biventricular mock loop uses two pneumatic pumps (Abiomed AB5000™, Danvers, MA, USA) driven by a dual-output driver (Thoratec Model 2600, Pleasanton, CA, USA). The drive pressures can be individually modified to simulate a healthy heart and left and/or right heart failure conditions, and variable compliance and fluid volume allow for additional customization. The loop output for a healthy heart was tested at 4.2 L/min with left and right atrial pressures of 1 and 5 mm Hg, respectively; a mean aortic pressure of 93 mm Hg; and pulmonary artery pressure of 17 mm Hg. Under conditions of left heart failure, these values were reduced to 2.1 L/min output, left atrial pressure = 28 mm Hg, right atrial pressure = 3 mm Hg, aortic pressure = 58 mm Hg, and pulmonary artery pressure = 35 mm Hg. Right heart failure resulted in the reverse balance: left atrial pressure = 0 mm Hg, right atrial pressure = 30 mm Hg, aortic pressure = 100 mm Hg, and pulmonary artery pressure = 13 mm Hg with a flow of 3.9 L/min. For biventricular heart failure, flow was decreased to 1.6 L/min, left atrial pressure = 13 mm Hg, right atrial pressure = 13 mm Hg, aortic pressure = 52 mm Hg, and pulmonary artery pressure = 18 mm Hg. This mock loop could become a reliable bench tool to simulate a range of heart failure conditions.

First In Vivo Experience With Biventricular Circulatory Assistance Using a Single Continuous Flow Pump

Biventricular assist device (BVAD) implantation is the treatment of choice in patients with severe biventricular heart failure and cardiogenic shock. Our team has developed a miniaturized continuous flow, double-ended centrifugal pump intended for total artificial heart implant (CFTAH). The purpose of this initial in vivo study was to demonstrate that the scaled-down CFTAH (P-CFTAH) can be appropriate for BVAD support. The P-CFTAH was implanted in 4 acute lambs (average weight, 41.5 ± 2.8 kg) through a median sternotomy. The cannulation was performed through the left and right atria, and cannulae length adjustment was performed for atrial and ventricular cannulation. The BVAD system was tested at 3 pump speeds (3000, 4500, and 6000 rpm). The BVAD performed very well for both atrial and ventricular cannulation within the 3000-6000 rpm range. Stable hemodynamics were maintained after implantation of the P-CFTAH. The self-regulating performance of the system in vivo was demonstrated by the left (LAP) and right (RAP) pressure difference (LAP-RAP) falling predominantly within the range of -5 to 10 mm Hg with variation, in addition to in vitro assessment of left and right heart failure conditions. Left and right pump flows and total flow increased as the BVAD speed was increased. This initial in vivo testing of the BVAD system demonstrated satisfactory device performance and self-regulation for biventricular heart failure support over a wide range of conditions. The BVAD system keeps the atrial pressure difference within bounds and maintains acceptable cardiac output over a wide range of hemodynamic conditions.

Differential microRNA-21 and microRNA-221 Upregulation in the Biventricular Failing Heart Reveals Distinct Stress Responses of Right Versus Left Ventricular Fibroblasts.

The failing right ventricle (RV) does not respond like the left ventricle (LV) to guideline-directed medical therapy of heart failure, perhaps due to interventricular differences in their molecular pathophysiology. Using the canine tachypacing-induced biventricular heart failure (HF) model, we tested the hypothesis that interventricular differences in microRNAs (miRs) expression distinguish failing RV from failing LV. Severe RV dysfunction was indicated by elevated end-diastolic pressure (11.3±2.5 versus 5.7±2.0 mm Hg; P<0.0001) and diminished fractional area change (24.9±7.1 versus 48.0±3.6%; P<0.0001) relative to prepacing baselines. Microarray analysis of ventricular tissue revealed that miR-21 and miR-221, 2 activators of profibrotic and proliferative processes, increased the most, at 4- and 2-fold, respectively, in RV-HF versus RV-Control. Neither miR-21 or miR-221 was statistically significantly different in LV-HF versus LV-Control. These changes were accompanied by more extensive fibrosis in RV-HF than LV-HF. To test whether miR-21 and miR-221 upregulation is specific to RV cellular response to mechanical and hormonal stimuli associated with HF, we subjected fibroblasts and cardiomyocytes isolated from normal canine RV and LV to cyclic overstretch and aldosterone. These 2 stressors markedly upregulated miR-21 and miR-221 in RV fibroblasts but not in LV fibroblasts nor cardiomyocytes of either ventricle. Furthermore, miR-21/221 knockdown significantly attenuated RV but not LV fibroblast proliferation. We identified a novel, biological difference between RV and LV fibroblasts that might underlie distinctions in pathological remodeling of the RV in biventricular HF.

Why the Diagnosis of ATTR-Cardiomyopathy May Be a Challenge for Physicians

Cardiac amyloidosis is a rare but life-threatening group of disorders caused by the extracellular deposition of misfolded amyloid fibrils in cardiac tissue. Amyloid accumulation leads to cardiomyocyte toxicity, extracellular volume expansion, and ventricular pseudohypertrophy. Two types of amyloid protein are thought to be responsible for most disorders: immunoglobulin light chain, which causes light chain amyloidosis (AL); and transthyretin (TTR), which causes transthyretin amyloidosis (ATTR), of which there are two types: hereditary (hATTR) or wild-type (ATTRwt). Despite increasing clinical recognition of the disease, cardiac amyloidosis remains underdiagnosed. This article explores the epidemiology of AL and ATTR and the noninvasive techniques that help to improve diagnosis of the disorder. Cardiac amyloidosis is associated with mixed phenotype symptoms of polyneuropathy and cardiomyopathy which can lead to multiple misdiagnoses. As a result, patients can wait between 2 and 4 years for a correct diagnosis. Early diagnosis may be aided by recognising red flag symptom clusters. These include family history; neuropathy and sensory involvement; bilateral carpal tunnel syndrome; early autonomic dysfunction and gastrointestinal complaints; heart failure (HF) with preserved ejection fraction (HFpEF; without hypertension); cardiac hypertrophy, arrhythmias, ventricular blocks, right-sided or biventricular HF, or cardiomyopathy; renal abnormalities; and vitreous opacities. Noninvasive imaging techniques have increasingly been used as an alternative to biopsy to diagnose cardiac amyloidosis with the hope of allowing physicians to provide targeted therapy for these patients. Techniques include speckle tracking echocardiography, cardiac MRI, and nuclear scintigraphy, together with biomarkers such as N-terminal pro-brain natriuretic peptide and hepatocyte growth factor (HGF). It is hoped that greater understanding of patients with ATTR may lead to increased awareness of the disorder and improve patient outcomes.

Iron Deficiency Is Associated with Adverse Outcomes in Pediatric Heart Failure

To evaluate the prevalence of iron deficiency and its association with outcomes in children with heart failure. A single-center retrospective cohort study of patients with heart failure aged 1-21years from July 2012 to June 2017 with available serum iron studies was performed. Subjects were analyzed in 2 groups: biventricular systolic heart failure (BiV) and single-ventricle congenital heart disease with systolic heart failure (SV). Iron deficiency was defined as ≥2 of the following: serum iron <50μg/dL, serum ferritin <20ng/mL, transferrin >300ng/mL, or transferrin saturation <15%. The primary outcome was a composite adverse event (CAE) of ventricular assist device implantation, heart transplantation, or death, at 3 and 6months from time of iron studies. Of the 107 subjects (77 BiV, 30 SV) included in the study, 56% were iron deficient. Demographics, etiology of heart failure, and chronicity of heart failure symptoms were not associated with iron deficiency. On multivariable analysis, in group BiV, iron deficiency was associated with CAE at 3months (79% iron deficiency in CAE group vs 37% iron deficiency in non-CAE, P=.001, OR 7, 95% CI 2-21) and 6months (76% iron deficiency in CAE vs 35% iron deficiency in non-CAE, P=.002, OR 7, 95% CI 2-24). In group SV, iron deficiency was associated with CAE at 6months (79% iron deficiency in CAE vs 29% iron deficiency in non-CAE, P=.014, OR 8, 95% CI 2-32). Iron deficiency was present in 56% of the pediatric patients with heart failure who were evaluated with iron studies. Iron deficiency was associated with greater risk of ventricular assist device implantation, heart transplantation, or death.

Initial United Kingdom experience with the syncardia total artificial heart

Introduction The SynCardia Total Artificial Heart (TAH) is a form of mechanical circulatory support where the patient's native ventricles and valves are explanted and replaced by a pneumatically powered artificial heart (1). Implantation is indicated in patients with irreversible biventricular cardiac failure (2). We have recently initiated a TAH program at Harefield Hospital for the UK patient population. The aim of this study is to review our initial experience in terms of success rate of bridging patients to transplantation and post cardiac transplant outcomes. Methods We analysed data from all patients who received a TAH from July 2014 until April 2019 at our institution to quantify the rate of successful bridging to transplantation and the subsequent post cardiac transplant outcomes. Results 22patients (males, n = 14; mean age 39 ± 17) received TAH implants due to severe, irrecoverable biventricular failure. Aetiologies were dilated (n = 11, 50%), ischaemic (n = 6, 27%) and valvular (n = 3, 13%) cardiomyopathies. 12 patients (55%) were on veno-arterial extra corporeal membrane oxygen support with mean duration of 8.3 ± 8.6 days prior to TAH implantation. Mean duration on TAH support was 95 ± 114 days. 7 patients (32%) suffered stroke, 8 (36%) required surgical exploration for bleeding and 7 (32%) developed sepsis. 9 patients (40%) were successfully bridged to and received a heart transplant, another 3 patients are on the waiting list. 6 patients (27%) are still living: 3 post heart transplantation and 3 remain on the waiting list for a heart transplant. Discussion We have successfully introduced The TAH program in the UK as an important and unique intervention for a high risk patient population with biventricular heart failure who are not candidates for left ventricular assist device. Despite high rate of perioperative and early mortality and postoperative complications TAH implantation provides a realistic alternative for these otherwise futile cases.

Functional outcomes in a patient with a total artificial heart

A patient with biventricular heart failure received a total artificial heart (TAH) as a bridge to transplant. He had a complicated hospital course including postoperative bleeding, subarachnoid hemorrhage, and adjustment disorder. After participating in 6 months of a rehabilitation program, his Berg balance score progressed from 8 to 41 and his endurance improved from ambulating 75 feet with a rolling walker and requiring moderate assistance in his activities of daily living on admission to ambulating several times up to 200 feet with modified independent and modified independent with setup for his basic activities of daily living. Since few patients have undergone inpatient rehabilitation with a TAH, this case illustrates significant functional gains that a comprehensive rehabilitation team can provide and major considerations to be aware of to optimize care when working with patients with TAH.

Bridging Biventricular Failure to Successful Heart Transplants: HVAD BiVAD versus TAH

Purpose LImited mechanical support options exist for patients in biventricular heart failure. Post-transplant outcomes in those bridged with BiVAD HVADs and Total Artificial Heart (TAH) have not been well described. We sought to examine post heart transplant outcomes of this cohort in a national registry. Methods 258 patients were bridged to transplant with the TAH and 54 patients with HVAD BiVAD were identified in the UNOS registry (2004-2018). Exclusions included age proportional hazard regression analysis (adjusted for age, sex, diabetes , race, ischemic time , dialysis, life support, waiting time & HLA mismatch) was performed. Results 312 patients underwent successful HT with either TAH or HVAD BiVAD. HVAD BiVAD recipients were younger (47.1 ± 16.3 vs 48.1 ± 14.0, p=0.003) and more likely to be female (33.3% vs 13.6%, p Multivariate analysis yielded a hazard ratio of 0.58 (CI 0.26 - 1.03) comparing HVAD BiVAD to TAH. Conclusion Patients with biventricular failure requiring mechanical support represent a high mortality cohort. Our study demonstrates that pts bridged with HVAD BiVAD have superior outcomes to those bridged with the TAH, which appears driven by early mortality with the TAH cohort. Further study is warranted to refine patient selection as both choices present unique challenges.