Incidence Of Right Heart Failure Research Articles

(93) Race and Incidence of Right Heart Failure after Left Ventricular Assist Device Implantation

(93) Race and Incidence of Right Heart Failure after Left Ventricular Assist Device Implantation

Pre-emptive intraoperative administration of PCC4 in cardiac surgery patients at high risk of bleeding: Apilot study.

Four-factor prothrombin complex (PCC4), a concentrate of factors II, VII, IX, and X and proteins C and S, has been used selectively for reversal of oral anticoagulation before surgery. There is data to support PCC4 as opposed to supplemental fresh frozen plasma (FFP) to manage postoperative bleeding following cardiac surgery. The preemptive, intraoperative use of PCC4 in cardiothoracic surgery has not been studied though it may prevent postoperative bleeding, the need for blood transfusion and the risk of transfusion-related acute lung injury, volume overload, and right ventricular (RV) heart failure. The purpose of this study is to evaluate the intraoperative administration of PCC4 to decrease bleeding and lower the rate of blood transfusion. A single institution retrospective chart review was conducted from May 2020 to November 2021 of patients who received PCC4 intraoperatively during cardiothoracic surgery of high-risk variety. Patients were evaluated for the type of surgery, demographics, baseline anticoagulation, PCC4 dose, type and quantity of blood transfusion within 72 hours (h) postoperatively, chest tube output, the incidence of RV failure, hypersensitivity reactions, acute kidney injury (AKI), thrombosis, acute lung injury, and mortality within 45 days of the operative dose of PCC4. Thirty-five patients received PCC4 at a mean dose of 2920 units (U). Sixty-fivepercent of cases were left ventricular assist devices(LVADs) or heart transplants. The protocol is to use PCC4 30 units (U)/kg immediately after the completion of protamine administration. Inclusion criteria are cardiothoracic surgery with increased risk of postoperative right heart failure commonly secondary to blood product transfusion, or cardiothoracic surgery associated with increased risk of bleeding, including heart transplant, LVAD implant, aortic dissection, and redo sternotomy (e.g., coronary artery bypass). Total chest tube output was recorded as a mean of 757 ml for 24 h after surgery (32 ml/h). Overall median event rates of FFPand red blood cell (RBC) transfusions were 0 (interquartile range [IQR]: 0-3 U) and 4 (IQR: 2-5 U). Overall, 43%and 89%of cases received FFP and RBC, respectively. There was one occurrence of RV failure, one occurrence of AKI requiring renal replacement therapy, one occurrence of venoarterial extracorporeal membrane oxygenation, one occurrence of venous thromboembolism related to a central venous access line, and one death unrelated to surgery or PCC4 that was attributed to advanced heart failure not amenable to advanced therapies. Overall patients received a low rate of blood transfusion, had minimal chest tube output, and there was a small incidence of right heart failure. Patients did not have an increased risk of adverse effects such as AKI or venous thromboembolism. A randomized controlled clinical trial comparing the observed dose and timing of PCC4 versus routine postoperative bleeding management with blood product transfusion is recommended.

Surgical Treatment of Tricuspid Valve Regurgitation in Patients Undergoing Left Ventricular Assist Device Implantation: Interim analysis of the TVVAD trial

ObjectivesRight heart failure remains a serious complication of left ventricular assist device therapy. Many patients presenting for left ventricular assist device implantation have significant tricuspid regurgitation. It remains unknown whether concurrent tricuspid valve surgery reduces postoperative right heart failure. The primary aim was to identify whether concurrent tricuspid valve surgery reduced the incidence of moderate or severe right heart failure within the first 6 months after left ventricular assist device implantation. MethodsPatients with moderate or severe tricuspid regurgitation on preoperative echocardiography were randomized to left ventricular assist device implantation alone (no tricuspid valve surgery) or with concurrent tricuspid valve surgery. Randomization was stratified by preoperative right ventricular dysfunction. The primary end point was the frequency of moderate or severe right heart failure within 6 months after surgery. ResultsThis report describes a planned interim analysis of the first 60 randomized patients. The tricuspid valve surgery group (n = 32) had mild or no tricuspid regurgitation more frequently on follow-up echocardiography studies compared with the no tricuspid valve surgery group (n = 28). However, at 6 months, the incidence of moderate and severe right heart failure was similar in each group (tricuspid valve surgery: 46.9% vs no tricuspid valve surgery: 50%, P = .81). There was no significant difference in postoperative mortality or requirement for right ventricular assist device between the groups. There were also no significant differences in secondary end points of functional status and adverse events. ConclusionsThe presence of significant tricuspid regurgitation before left ventricular assist device is associated with a high incidence of right heart failure within the first 6 months after surgery. Tricuspid valve surgery was successful in reducing postimplant tricuspid regurgitation compared with no tricuspid valve surgery but was not associated with a lower incidence of right heart failure.

When Nothing Goes Right: Risk Factors and Biomarkers of Right Heart Failure after Left Ventricular Assist Device Implantation.

Right heart failure (RHF) is a severe complication after left ventricular assist device (LVAD) implantation. The aim of this study was to analyze the incidence, risk factors, and biomarkers for late RHF including the possible superiority of the device and implantation method. This retrospective, single-center study included patients who underwent LVAD implantation between 2014 and 2018. Primary outcome was freedom from RHF over one-year after LVAD implantation; secondary outcomes included pre- and postoperative risk factors and biomarkers for RHF. Of the 145 consecutive patients (HeartMate 3/HVAD: n = 70/75; female: 13.8%), thirty-one patients (21.4%) suffered RHF after a mean LVAD support of median (IQR) 105 (118) days. LVAD implantation method (less invasive: 46.7% vs. 35.1%, p = 0.29) did not differ significantly in patients with or without RHF, whereas the incidence of RHF was lower in HeartMate 3 vs. HVAD patients (12.9% vs. 29.3%, p = 0.016). Multivariate Cox proportional hazard analysis identified HVAD (HR 4.61, 95% CI 1.12–18.98; p = 0.03), early post-op heart rate (HR 0.96, 95% CI 0.93–0.99; p = 0.02), and central venous pressure (CVP) (HR 1.21, 95% CI 1.05–1.39; p = 0.01) as independent risk factors for RHF, but no association of RHF with increased all-cause mortality (HR 1.00, 95% CI 0.99–1.01; p = 0.50) was found. To conclude, HVAD use, lower heart rate, and higher CVP early post-op were independent risk factors for RHF following LVAD implantation.

Prognostic impact of functional mitral regurgitation prior to left ventricular assist device implantation

BackgroundFunctional mitral regurgitation (FMR) is a common finding of advanced heart failure with detrimental effects. The prognostic impact of uncorrected FMR prior to left ventricular assist device (LVAD) implantation remains controversial.MethodsBetween 2016 and 2019 77 patients underwent continuous-flow LVAD implantation at our institution. 34 patients showed FMR ≥ 2 (MR-group), whereas 43 patients showed FMR < 2 (Control-group). Data was retrospectively analyzed. Primary composite endpoint comprised freedom from death, stroke, pump-thrombosis, major bleeding and right heart failure (RHF) after 1 year.ResultsBaseline characteristics, including the severity of left and right ventricular dysfunction, and periprocedural results were comparable. The overall survival during a mean follow up of 24.9 months was 55.9% in the MR-group versus 58.1% in the Control-group (p = 0.963), whereas 1-year event-free survival was 35.3% in the MR-group compared to 44.2% in the Control-group (p = 0.404). RHF within the first postoperative year occurred more frequently in the MR-group (35.3% vs. 11.6%; p = 0.017). Furthermore, RV function was significantly reduced in comparison to baseline values in the MR-group. 12 months after surgery, 74% of patients in the MR-group were classified as NYHA III in comparison to 24% of patients in the Control-group (p < 0.001).ConclusionsPreoperative uncorrected FMR prior to LVAD implantation did not affect overall survival, nevertheless it was associated with an impaired RV function and increased incidence of right heart failure during follow-up. Furthermore, preoperative FMR ≥ 2 was associated with persistent symptoms of heart failure.

Impact of severe mitral regurgitation on postoperative outcome after durable left-ventricular assist device implantation.

Mitral valve regurgitation (MR) is a common finding in patients with end-stage heart failure. The aim of the study was to analyze the impact of preoperative moderate-to-severe MR on postoperative outcomes and survival after durable left-ventricular assist device (LVAD) implantation. From August 2010 to May 2021, 246 patients underwent a durable LVAD implantation. We stratified the patients into two groups: Group A (n=109) presented with MR 0-I°, and Group B presented with MR II-III° (n=137). MR II-III° was defined according to the current recommendations (i.e., vena contracta ≥ 7 mm, regurgitation volume ≥ 30 ml or effective regurgitation orifice area ≥ 20 mm2 ). Significantly more patients in Group B suffered from pulmonary hypertension and presented with chronic obstructive lung disease. We observed significantly higher rates of tricuspid regurgitation (TR) II-III° in Group B (76.1%) versus Group A (14.8%) (p<0.001) and TR III° in Group B (30.4%) versus Group A (3.7%) (p<0.001). There was no difference in the incidence of right heart failure between the groups. Within our cohort, the in-hospital, 1-year, 3-year, and 5-year mortality was 22.4%, 32.1%, 50.7%, and 64.4%, respectively. Group B showed significantly worse overall survival (p=0.05). Patients with preoperative TR II-III° had a significantly worse survival than those with TR 0-I° (p=0.048). In patients presenting with MR II-III°, we discovered that TR III° seems to predict both in-hospital and mid-term mortality. MR II-III° negatively affects the outcomes in patients requiring LVAD implantation. Persisting MR II-III° is an independent predictor of mortality. Patients with concomitant preoperative TR II-III° are at increased risk of developing postoperative major adverse events. Addressing the MR might be considered for these patients.

Evolution of Late Right Heart Failure With Left Ventricular Assist Devices and Association With Outcomes

BackgroundA revised definition of right heart failure (RHF) for the Society of Thoracic Surgeons Intermacs database of left ventricular assist devices (LVADs) was introduced in June 2014. ObjectivesThe purpose of this study was to determine the prevalence and severity of RHF over time and the association of RHF status at 3 months with 12-month outcomes after LVAD. MethodsAll patients in Society of Thoracic Surgeons Intermacs with follow-up and supported at least 3 months with a continuous flow LVAD implanted between June 2, 2014 and March 31, 2017 without a simultaneous RVAD. RHF was defined as both documentation and manifestations of elevated central venous pressures. ResultsThere were 6,118 patients included with an incidence of RHF at 3, 6, and 12 months postimplant categorized as mild in 5%, 6%, and 6% and moderate in 5%, 3%, and 3%, respectively. For those with no RHF at 3 months, there was a low incidence of subsequent RHF at 6 and 12 months. The lack of RHF at 3 months, compared with mild and moderate RHF, was associated with a lower 12-month cumulative incidence of mortality (6.9% vs 16.7% vs 28.1%; P < 0.0001) and a lower 12-month cumulative incidence of stroke (7.4% vs 9.5% vs 11.0%; P = 0.0095), gastrointestinal bleeding (14.8% vs 24.2% vs 23.6%; P < 0.0001), and rehospitalization (65.2% vs 73.2% vs 71.2%; P < 0.0001). ConclusionsIn patients surviving 3 months with LVAD support alone, mild or moderate RHF occurred in nearly 1 of 10 patients at 12 months. Patients with late RHF had worse survival and a higher cumulative incidence of major adverse events.

Limitation of ROC in Evaluation of Classifiers for Imbalanced Data

PurposeROC is a common evaluation metric for risk scores and classifiers for mortality and adverse events. However, ROC can provide a misleadingly optimistic view of the performance of a classifier when the data are imbalanced, for example when proportion of adverse events is very small. This study illustrates the ambiguity of ROC through a case study of a classifier for post-LVAD Right Heart Failure (RHF), and illustrates the utility of the Precision Recall Curve (PRC) as a supplemental evolution tool.MethodsThis study included 11,967 patients recorded in INTERMACS who received a continuous-flow LVAD between 2006 and 2016 (mean age of 57; 21% female and 79% male) in which the incidence of RHF was only 9% at 1 year (1,079 patients). These data were randomly split into a training set (60%) and test set (40%). A logistic regression was developed using the training data to predict the post-LVAD RHF.ResultsROC in Fig.1.A indicates good performance of the RHF classifier with Area Under Curve (AUC) of 0.83. This is in contrast with the PRC in Fig.1. B with AUC of 0.33 shows the precision of the classifier drops rapidly from 1 (100%) to 0.4 (40%) as recall (sensitivity) increases slightly greater than 0%. The gray dot in Fig.1. A indicates the optimized point of equalized sensitivity and specificity of approximately 76-77%. In contrast, the corresponding precision of the classifier for the same sensitivity (76%) is only 23%. (See gray point in Fig.1.B) This means that only 23% of predicted RHF by this classifier is correct (True RHF). Thus, the preponderance (77%) of patients predicted to experience RHF are incorrectly classified (False RHF). The enormous predicted False RHF was not captured by ROC because False RHF in calculation of specificity is overwhelmed by the huge number of observed patients in the denominator who are free from RHF.ConclusionThe ROC can portray an overly-optimistic performance of a classifier or risk score when applied to imbalanced data. The PRC provide informative insight about the performance of classifier by focusing on the minority class. ROC is a common evaluation metric for risk scores and classifiers for mortality and adverse events. However, ROC can provide a misleadingly optimistic view of the performance of a classifier when the data are imbalanced, for example when proportion of adverse events is very small. This study illustrates the ambiguity of ROC through a case study of a classifier for post-LVAD Right Heart Failure (RHF), and illustrates the utility of the Precision Recall Curve (PRC) as a supplemental evolution tool. This study included 11,967 patients recorded in INTERMACS who received a continuous-flow LVAD between 2006 and 2016 (mean age of 57; 21% female and 79% male) in which the incidence of RHF was only 9% at 1 year (1,079 patients). These data were randomly split into a training set (60%) and test set (40%). A logistic regression was developed using the training data to predict the post-LVAD RHF. ROC in Fig.1.A indicates good performance of the RHF classifier with Area Under Curve (AUC) of 0.83. This is in contrast with the PRC in Fig.1. B with AUC of 0.33 shows the precision of the classifier drops rapidly from 1 (100%) to 0.4 (40%) as recall (sensitivity) increases slightly greater than 0%. The gray dot in Fig.1. A indicates the optimized point of equalized sensitivity and specificity of approximately 76-77%. In contrast, the corresponding precision of the classifier for the same sensitivity (76%) is only 23%. (See gray point in Fig.1.B) This means that only 23% of predicted RHF by this classifier is correct (True RHF). Thus, the preponderance (77%) of patients predicted to experience RHF are incorrectly classified (False RHF). The enormous predicted False RHF was not captured by ROC because False RHF in calculation of specificity is overwhelmed by the huge number of observed patients in the denominator who are free from RHF. The ROC can portray an overly-optimistic performance of a classifier or risk score when applied to imbalanced data. The PRC provide informative insight about the performance of classifier by focusing on the minority class.

The deleterious effect of intracardiac pacing leads on right ventricular function.

Aim: The aim of this study was to evaluate the progression of tricuspid regurgitation (TR) in patients with pacemaker leads across the tricuspid valve and assess the clinical effect on right ventricular (RV) function.Methods: Patients who had undergone permanent pacemaker implantation at our institution over an 8-year period were identified. Those who had an echo (for any indication) pre- and postdevice implantation were included in this study, and their data assessed. Clinical information was obtained from their medical records. A total of 65 patients (mean age 70 ± 13 years, 31 (48%) males, and 34 (52%) females) were enrolled in the study.Results: The median interval of echo after implantation was 12 (12 to 24) months. Before implantation, 29 patients had TR, which increased to 51 (78%) during follow up, indicating that 22 patients developed new TR. Of those with preexisting TR, the grade of TR had worsened by at least one grade in 17 patients. RV function as measured by tricuspid annular plane systolic excursion (TAPSE) had decreased from 1.87 ± 0.44 to 1.68 ± 0.42 (p = 0.002). Eighteen patients had developed signs of right heart failure (either breathlessness with raised jugular venous pressure or pedal edema or both), of which 13 had only new pedal edema.Conclusion: There is a definite progression of TR in patients with a pacing lead across the tricuspid valve (TV) associated with an increase in the incidence of right heart failure. Patients with a pacing lead across the TV should be followed closely for signs of right heart failure.

The incidence, risk factors and prognosis of acute kidney injury in severe and critically ill patients with COVID-19 in mainland China: a retrospective study

BackgroundThe clinical correlates, prognosis and determinants of acute kidney injury (AKI) in patients with coronavirus disease 2019 (Covid-19) remain largely unclear.MethodsWe retrospectively reviewed medical records of all adult patients with laboratory-confirmed Covid-19 who were admitted to the intensive care unit (ICU) between January 23rd 2020 and April 6th 2020 at Wuhan JinYinTan Hospital and The First Affiliated Hospital of Guangzhou Medical University.ResultsAmong 210 patients, 131 were males (62.4%). The median Age was 64 years (IQR: 56–71). Of 92 (43.8%) patients who developed AKI during hospitalization, 13 (14.1%), 15 (16.3%) and 64 (69.6%) were classified as being at stage 1, 2 and 3, respectively. 54 patients (58.7%) received continuous renal replacement therapy. Age, sepsis, nephrotoxic drug, invasive mechanical ventilation and elevated baseline serum creatinine levels were associated with the occurrence of AKI. Renal recovery during hospitalization was identified among 16 patients with AKI (17.4%), who had a significantly shorter time from admission to AKI diagnosis, lower incidence of right heart failure and higher ratio of partial pressure of oxygen to the fraction of inspired oxygen. Of 210 patients, 93 deceased within 28 days of ICU admission. AKI stage 3, critical disease, greater Age and the lowest ratio of partial pressure of oxygen to the fraction of inspired oxygen being < 150 mmHg were independently associated with death.ConclusionsAmong patients with Covid-19, the incidence of AKI was high. Our findings of the risk factors of the development of AKI and factors associated with renal function recovery may inform clinical management of patients with critical illness of Covid-19.

Short and Long Term Mortality in Patients with Right Heart Failure after Left Ventricular Assist Device Placement

Introduction The incidence of right heart failure (RHF) after left ventricular assist device (LVAD) placement ranges reportedly from 10-40%. We determined to analyze the short and long term mortality rates for those with RHF after LVAD placement. Methods In a single academic center, we conducted a retrospective analysis of those implanted with a LVAD from 2013 to 2019, and the incidence of postoperative RHF during index admission. Charts with insufficient data were excluded. RHF was defined via the classifications designated by INTERMACS, and patients were categorized into INTERMACS mild, moderate or severe RHF. Cox proportional analysis were performed for Kaplan Meyer curves for 1 and 5-year survival rates. Results A total of 136 LVAD implantations met criteria in which 22.1% were implanted as bridge to transplant and 77.9% as destination therapy. RHF was diagnosed in 44.1% of patients, in which 14.7%, 17.7%, and 11.8% were categorized as INTERMACS mild, moderate, and severe RHF respectively. Ninety-day mortality rates for patients with INTERMACS mild, moderate, and severe RHF were 15%, 10.9%, and 37.5%. The combined 90-day mortality rate for all patients with RHF was 23%. One-year mortality rates (FIGURE 1) for INTERMACS mild, moderate, and severe RHF were 20%, 25%, and 43.8%. The combined 1-year mortality rate for all patients with RHF was 28.3%, which contrasted the 1-year mortality rate for patients without RHF of only 6.7%. Five-year mortality rates (FIGURE 2) for INTERMACS mild, moderate, and severe RHF were 40%, 42.7% and 43.8%. The combined 5-year mortality rate for all patients with RHF was 41.2%, which contrasted the 5-year mortality rate for patients without RHF of 19.7%. For those with RHF who received temporary right VAD (tRVAD) support post-operatively, the average INTERMACS RHF severity was moderate. Ninety-day mortality rates for those with early tRVAD (≤24 hours) and delayed tRVAD (>24 hours) were 25% and 75%. Of those who received tRVAD, the 1-year mortality rate was 25% for those with early tRVAD, while those with delayed tRVAD had a 1-year mortality of 100% and all died on index admission. The 5-year mortality rate for those with RHF and early tRVAD was 50%. Total 90-day mortality for all patients (with and without RHF) was 16.2%. Total 1-year mortality for all patients was 11.7%. Conclusions In our study, 44.1% of patients had RHF after LVAD implantation with nearly 1/3 dying within 1 year. Implantation of early tRVAD seemingly improved 1 year survival as compared to INTERMACS severe RHF.

Impact of Tricuspid Valve Repair for Moderate Tricuspid Regurgitation at the Time of Left Ventricular Assist Device Implantation on the Occurrence of Right Heart Failure

Significant tricuspid regurgitation (TR) in patients undergoing durable left ventricular assist device (LVAD) implantation has been associated with increased incidence of right heart failure (RHF). There is great surgical practice variability related to moderate TR repair at the time of LVAD implantation. In this single-center study, we investigated whether moderate TR repair concurrent with LVAD implantation has impact on late RHF occurrence. We gathered data on adult patients undergoing durable LVAD implantation between 2009 and 2017. Only patients with moderate TR at the time of LVAD implantation constituted the study cohort. Patients were separated in two groups, concurrent tricuspid valve repair (TVr group) and no-TVr group. LateRHF was defined as any readmission for HF, requiring treatment with diuretics or inotropes or implantation of a right ventricular assist device. Unrepaired TR was categorized as improved if it was persistently graded as mild or less on post-operative echocardiographic studies. TVr failure was defined as moderate or severe TR on any post-operative echocardiographic study. Kaplan-Meier curves were used to analyze freedom from late RHF between the two groups. Out of 140 patients, 92 (65%) were in the TVr group. TVr failure was present in 35 (38%) of these patients. Out of the 48 patients in the no-TVr group, 22 (45%) experienced improvement of TR. Late RHF occurred in 12 (25%) patients in the no-TVr group and 35 (38%) patients in the TVr group. There was no event-free survival difference between the two groups (log rank p=0.678)(Figure). In our study cohort, we found no benefit in concurrent TVr for moderate TR at LVAD implantation on late RHF occurrence. Moreover, 45% of the patients with unrepaired moderate TR experienced improvement of TR, while 38% of patients with TVr experienced repair failure. Future randomized studies should address and confirm these results.

P108 Clinical effect of tricuspid regurgitation caused by pacemaker lead

Abstract Aim It is known that the presence of cardiac pacemaker leads across the tricuspid valve (TV) can lead to tricuspid regurgitation (TR). However the clinical implications of this are not known. The aim of this study was to evaluate the progression of TR in patients with pacemaker leads across the TV and assess the clinical effect on Right ventricular function. Methods Patients who had undergone cardiac device implantation (either pacemaker or implantable cardiac defibrillators) in our institution over a 5 years period were identified. Those who had an echo (for any indication) pre and post device implantation were included in this study and their data assessed. Clinical information was obtained from medical records Results A total of 65 patients (mean age 70 + 13 years, 31 (48%) male and 34 (52%)female) were enrolled in the study. The median follow up after implantation was 12 (12-24) months. At baseline 29 patients had TR before implantation which increased to 51 (78%) during follow up, indicating that 22 patients developed new TR. Of those with pre existing TR, 17 had worsening of TR by at least one grade. RV function as measured by TAPSE had decreased from 1.87+ 0.44 to 1.68 +0.42 p = 0.002 . Six patients developed RV dilatation during follow up. 18 patients had developed signs of Right heart failure (either breathlessness with raised jugular venous pressure or pedal oedema or both), of which 13 had only new pedal oedema. There was no difference in comorbidities or the percentage of pacing in the groups that had worsening of TR or RV dilatation. Conclusion There is definite worsening or development of new TR in patients with a pacing lead across the TV. This is associated with an increase in the incidence of right heart failure suggesting that this is not benign. However there does not appear to be any specific risk factor identified that is responsible for this. Changes after pacemaker implantation Pre pacemaker Post pacemaker p value Presence of TR (n) 29 51 0.018 RV dilatation(n) 5 11 0.01 TAPSE (mm) 1.87 + 0.44 1.68 + 0.42 0.002 Presence of pedal oedema(n) 5 13 0.01 TR grade grade 0 Grade 1 Grade2 Grade 3 Grade 4 36 9 16 3 0 14 3 31 16 2 0.008 TR- tricuspid regurgition, TAPSE- Tricuspid annular plane systolic excursion; RV- right ventricle

Moderate Aortic Insufficiency with a Left Ventricular Assist Device Portends a Worse Long-Term Survival.

The development of aortic insufficiency (AI) is known to be associated with prolonged left ventricular assist device (LVAD) support, but its overall significance with regards to long-term outcomes is unclear. This uncertainty translates to a lack of consensus regarding the management of AI in this patient population-an increasingly pertinent question as more patients are placed on LVAD support as destination therapy. A retrospective review of a single, high-volume institution was performed to assess outcomes in patients who received a HeartMate II or HeartWare (LVAD) between 2008 and 2018. Patients were stratified by AI severity at 6 months, and those with LVAD support of less than 6 months were excluded. The primary endpoint was 2 year mortality, and secondary endpoints were right heart failure and functional exercise capacity. At 6 month follow-up 111, 92, and 18 patients had no (0), mild (1), and moderate (2) AI, respectively. Moderate AI was a significant predictor of 2 year mortality in a multivariable model (p = 0.024). Functional exercise capacity (measured by 6 minute walk test) and incidence of right heart failure at 1 year were not significantly different between groups (P = 0.1421; P = 0.2189). In conclusion, moderate AI at 6 months post-LVAD implant is associated with worse long-term mortality. More aggressive management strategies targeting AI development in long-term LVAD patients may be warranted.

Right Heart Failure in Different Left Ventricular Assist Devices: Single-Center Experience.

Background: Right heart failure (RHF) following left ventricular assist device (LVAD) implantation increases morbidity and mortality for those who develop this complication. The purpose of this study was to assess the differences in incidence of RHF and outcomes between 2 types of continuous-flow LVADs at a single center. Methods: From January 2012 through June 2016, 184 patients were implanted with a continuous-flow LVAD (161 patients with the HeartMate II and 23 patients with the HeartWare device) either as a bridge to transplant or as destination therapy. Preoperative demographics, medical history, laboratory values, hemodynamics, and device type were analyzed to determine the variables associated with RHF and mortality. Results: Preoperative variables between the 2 groups were homogeneous. Most patients were Interagency Registry for Mechanically Assisted Circulatory Support profile 1 or 2 (92%) and New York Heart Association class IV (81%). More patients in the HeartMate II group had the indication of destination therapy (54% vs 30%), while more patients in the HeartWare group were implanted as bridge to transplant (70% vs 46%). RHF occurred in 57% of HeartWare patients compared to 16% of patients who received the HeartMate II (P=0.0001). After propensity score analysis, patients receiving the HeartWare device had increased odds for RHF (P=0.0013) and renal failure requiring dialysis (P=0.0135). The HeartMate II patient survival rate exceeded the HeartWare patient survival rate at 1 year (82.1% vs 67.2%) and at 2 years (74.6% vs 61.7%), but this difference did not achieve statistical significance (log-rank P=0.087). Conclusion: These results indicate that device type may affect RHF incidence and mortality. Studies at other centers are needed to replicate these findings.

Low Incidence of Right Heart Failure During Left Ventricular Assist Device Implantation

Low Incidence of Right Heart Failure During Left Ventricular Assist Device Implantation

English

BACK GROUND: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in countries of high, middle, and low income. Estimates from WHO's Global Burden of Disease and Risk Factors project show that in 2001, COPD was the fifth leading cause of death in high-income countries, accounting for 3.8% of total deaths, and it was the sixth leading cause of death in nations of low and middle income, accounting for 4·9% of total deaths. OBJECTIVES: 1. To study clinical parameters of chronic obstructive pulmonary disease. 2. To find out Electrocardiographic changes of chronic obstructive pulmonary disease. 3. To confirm with echocardiogram the presence of pulmonary hypertension, tricuspid regurgitation and right heart failure and analyze the incidence of right heart failure and pulmonary hypertension. MATERIALS AND METHODS: Single center hospital based cross sectional study. Patients diagnosed as COPD based on following steps will be included in the study. The patients with cough, sputum production, dyspnoea (wheeze) was chosen (sputum AFB negative will be confirmed). Pulmonary function test was done to pick up patients with reduced FEV 9 mm, as this is the one of the indication for life long oxygen therapy as per American Thoracic Society (ATS). Out of 72 patients, 12 had coronary artery disease (CAHD) as this increases the incidence of cor-pulmonale. CARDIOVASCULAR COMPLICATIONS: Out of 72 patients, 24% developed pulmonary hypertension, 22% developed tricuspid regurgitation, 34% had p-pulmonale, 18% had p-wave amplitude in lead-II + lead-III + lead a VF >9 mm, this is important because this is one of the indication for life long oxygen therapy. 18% had concomitant coronary artery disease (CAHD), this observation is important because systemic inflammation plays enhanced role in atherosclerosis, diabetes mellitus, tumour necrosis factor is increased in COPD patients. CONCLUSION: Pulmonary hypertension was the most common cardiovascular complication leading to corpulmonale, and emphysema was more common in smokers, bronchitis was more common in females, the prevalence of COPD was more in urban areas due to pollution of air by automobiles. The textile based industries were mainly responsible for the increased prevalence of COPD.

Does Acuity of Presentation Impact the Incidence of Right Ventricular Failure Following Left Ventricular Assist Device Implantation?

Purpose We sought to examine the incidence of right ventricular failure (RVF) and survival in patients with ischemic cardiomyopathy (ICM), according to acuity of presentation. Methods and Materials All patients with ICM receiving a continuous-flow (CF) left ventricular assist device (LVAD) after 2007 were included. Acute presentation was defined as no previous history of heart failure and occurring in the setting of acute myocardial infarction (MI). All acute patients were in INTERMACS profile 1. RVF was defined as per INTERMACS criteria. Results Between June 2007 and August 2012, 111 patients with ICM underwent implantation of a CF LVAD (106 Heartmate II, 5 HeartWare). There were 29 patients that presented acutely. Patients with acute ICM (n=82) were significantly younger (mean age 57±8.4 vs. 61.6±8.1 years, p=0.01) than patients with chronic ICM. Also, chronic ICM patients had a significantly greater proportion of cardiovascular comorbidities than acute ICM patients. Pulmonary artery systolic pressure (mean 54.4±16.7 vs. 41.5±15.7 mmHg, p=0.002) and LV end-diastolic dimension (6.7 vs. 5.4 cm, p Conclusions The incidence of right heart failure appears to be lower among patients with an acute presentation of ICM compared to those with chronic ICM after implantation of a CF LVAD. Despite circulatory collapse in the acute group of patients, superior right heart function and a lower burden of cardiovascular comorbidities may produce a mid-term survival that is comparable to patients with chronic ICM after LVAD.

Reversible Pulmonary Hypertension in Heart Transplant Candidates: To Transplant or Not to Transplant

Pulmonary hypertension (PHT), defined as a pulmonary vascular resistance (PVR) greater than 2.5 Wood units [WU] and(or) transpulmonary gradient (TPG) greater than 12 mm Hg, is a risk factor for mortality in cardiac transplantation due to elevated postoperative right heart failure. Orthotopic heart transplantation is possible if PVR could be reversed below 2.5 WU and TPG below 12 mm Hg. We show the Muenster experience from the last 10 years. From April 1996 to December 2005 all cardiac transplant recipients separated into patients with and without PHT were included. All patients with PHT had successful reduction (PVR < or = 2.5 WU and TPG < or = 12 mm Hg) using prostaglandin I2 or E1. Posttransplant early and late mortality and incidence of right heart failure were studied. Two hundred seventeen patients were included in this study. Of these, 168 had normal pulmonary pressures (non-PHT group), 49 (22.6%) had reversible PHT (rev-PHT group). Mean PVR was 1.6 +/- 1.1 WU vs 2.1 +/- 1.1 WU (p < 0.01; non-PHT vs rev-PHT) and mean TPG 8.0 +/- 1.9 mm Hg vs 10.6 +/- 4.1 mm Hg (p = not significant [NS]). Thirty-day survival after orthotopic cardiac transplantation was 85% vs 78% (p = 0.150) and 10 year survival 63% vs 61% (p = NS). Right heart failure during the first 30 days after transplantation occurred in 27% in the non-PHT group and in 64% in the rev-PHT group (p = 0.035). However, in patients transplanted after 2001 it did not appear. Cardiac transplant candidates with reversible PHT have still significantly elevated pulmonary pressures compared with patients without PHT. Despite a significantly higher risk of right heart failure, long-term survival after orthotopic cardiac transplantation was not affected.