Inotrope Dependence Research Articles

Hospital Readmissions in Patients Supported with Durable Centrifugal-Flow Left Ventricular Assist Devices.

Background: Centrifugal-flow left ventricular assist devices (CF-LVADs) have improved morbidity and mortality for their recipients. Hospital readmissions remain common, negatively impacting quality of life and survival. We sought to identify risk factors associated with hospital readmissions among patients with CF-LVADs. Methods: Consecutive patients receiving a CF-LVAD between February 2011 and March 2021 were retrospectively evaluated using prospectively maintained institutional databases. Hospital readmissions within three years post-LVAD implantation were dichotomized into heart failure (HF)/LVAD-related or non-HF/LVAD-related readmissions. Multivariable Cox regression models augmented using a machine learning algorithm, the least absolute shrinkage and selection operator (LASSO) method, for variable selection were used to estimate associations between HF/LVAD-related readmissions and pre-, intra- and post-operative clinical variables. Results: A total of 204 CF-LVAD recipients were included, of which 138 (67.7%) had at least one HF/LVAD-related readmission. HF/LVAD-related readmissions accounted for 74.4% (436/586) of total readmissions. The main reasons for HF/LVAD-related readmissions were major bleeding, major infection, HF exacerbation, and neurological dysfunction. Using pre-LVAD variables, HF/LVAD-related readmissions were associated with substance use, previous cardiac surgery, HF duration, pre-LVAD inotrope dependence, percutaneous LVAD/VA-ECMO support, LVAD type, and the left ventricular ejection fraction in multivariable analysis (Harrell's concordance c-statistic; 0.629). After adding intra- and post-operative variables in the multivariable model, LVAD implant hospitalization length of stay was an additional predictor of readmission. Conclusions: Using machine learning-based techniques, we generated models identifying pre-, intra-, and post-operative variables associated with a higher likelihood of rehospitalizations among patients on CF-LVAD support. These models could provide guidance in identifying patients with increased readmission risk for whom clinical strategies to mitigate this risk may further improve LVAD recipient outcomes.

Cardiac resynchronization therapy in inotrope-dependent heart failure: a meta-analysis.

The viability of cardiac resynchronization therapy (CRT) in inotrope-dependent heart failure (HF) has been a matter of debate. We searched Medline, EMBASE, Scopus, and the Cochrane Library until 31 December 2022. Studies were included if (i) HF patients required inotropic support at CRT implantation; (ii) patients were ≥18years old; and (iii) they provided a clear definition of 'inotrope dependence' or 'inability to wean'. A meta-analysis was performed in R (Version 3.5.1). Nineteen studies comprising 386 inotrope-dependent HF patients who received CRT (mean age 64.4years, 76.9% male) were included. A large majority survived until discharge at 91.1% [95% confidence interval (CI): 81.2% to 97.6%], 89.3% were weaned off inotropes (95% CI: 77.6% to 97.0%), and mean discharge time post-CRT was 7.8days (95% CI: 3.9 to 11.7). After 1year of follow-up, 69.7% survived (95% CI: 58.4% to 79.8%). During follow-up, the mean number of HF hospitalizations was reduced by 1.87 (95% CI: 1.04 to 2.70, P<0.00001). Post-CRT mean QRS duration was reduced by 29.0ms (95% CI: -41.3 to 16.7, P<0.00001), and mean left ventricular ejection fraction increased by 4.8% (95% CI: 3.1% to 6.6%, P<0.00001). The mean New York Heart Association (NYHA) class post-CRT was 2.7 (95% CI: 2.5 to 3.0), with a pronounced reduction of individuals in NYHA IV (risk ratio=0.27, 95% CI: 0.18 to 0.41, P<0.00001). On univariate analysis, there was a higher prevalence of males (85.7% vs. 40%), a history of left bundle branch block (71.4% vs. 30%), and more pronounced left ventricular end-diastolic dilation (274.3±7.2 vs. 225.9±6.1mL). CRT appears to be a viable option for inotrope-dependent HF, with some of these patients seeming more likely to respond.

A systematic review and meta-analysis of cardiac resynchronization therapy in inotrope-dependent heart failure: an update

Abstract Background Inotrope-dependent heart failure (HF) carries a poor prognosis. Advanced mechanical supports have been viewed as primary treatment modalities for these patients, but cardiac resynchronization therapy (CRT) is an emerging alternative. Whether CRT is viable in HF patients who require inotropic support is uncertain. Purpose To assess outcomes of CRT in end-stage inotrope-dependent HF. Methods Following PRISMA guidelines, we searched Medline, EMBASE, Scopus, and Cochrane Library until December 31st 2022, with the following terms: "end-stage heart failure," "catecholamine-dependent overt heart failure," "inotrope-dependent heart failure," "advanced heart failure," "New York Heart Association class IV," "NYHA class IV." These terms were combined with "cardiac resynchronization therapy" OR "CRT" OR "biventricular device". Studies were included if: 1) HF patients required on inotropic support at CRT implantation; 2) patients were at least 18 years old; and 3) provided a clear definition of "inotrope dependence" or "inability to wean." A meta-analysis with random effects was performed in R (Version 3.5.1) with data presented as mean ± standard error. Results 19 studies comprised of 386 inotrope-dependent HF patients (mean age 64.4 ± 1.2 years, 76.9% male, 54.6% non-ischemic cardiomyopathy, mean QRS duration 168.0 ± 4.6 ms, mean follow-up 778 ± 110.7 days) were included for meta-analysis. A large majority of patients survived until discharge at 90% (95% CI: 81.0%-96.8%, I2=51%, p=0.04, Figure 1A), 88.6% were weaned off inotropes (95% CI: 77.5%-96.8%, I2=64%, p&amp;lt;0.01), and mean time to discharge post-CRT was 7.8 days (95% CI: 3.9-11.7, I2= 84%, p&amp;lt;0.01). After one year of follow-up 69.5% survived (95% CI: 59.2%-78.9%, I2=53%, p=0.02, Figure 1B) and 59.1% (95% CI: 50.1%-67.8%, I2=58%, p&amp;lt;0.01, Figure 1C) were alive at the end of follow-up. During follow-up the mean number of hospital admission for HF was reduced by 1.87 (95% CI: 2.70-1.04, I2=77%, p=0.04). Post-CRT mean QRS duration was reduced by 29.0 ms (95% CI: 41.33-16.68, I2=69%, p=0.006, Fig) and mean left ventricular ejection fraction increased by 4.83% (95% CI: 3.09%-6.57%, I2=16%, p=0.31, Fig). The mean NYHA class post-CRT was 2.7 (95% CI: 2.5-3.0, I2=56%, p=0.03, Figure 2A), 39.6% (95% CI: 18,.7%-62.3%, I2=83%, p&amp;lt;0.01, Figure 2C) improved to NYHA class III and 34.6% (95% CI: 16.4%-55.2%, I2=79%, p&amp;lt;0.01, Figure 2D) improved to NYHA class II. Responders to CRT tended be male (85.7% vs. 40%, p=0.015), have a history of left bundle branch block (71.4% vs. 30%, p=0.036) or an increased left ventricular end-diastolic volume (274.3 mL vs. 225.9 mL, p=0.038). Conclusion(s) Our results suggest that CRT is an alternative option for end-stage inotrope-dependent HF, improving survival, NYHA status, and HF readmission. CRT responders appear to be male with evidence of preserved diastolic function or a history of a left bundle branch block.

PO-02-012 A SYSTEMATIC REVIEW AND META-ANALYSIS OF CARDIAC RESYNCHRONIZATION THERAPY IN INOTROPE-DEPENDENT HEART FAILURE

Several studies have shown cardiac resynchronization therapy (CRT) to be beneficial in the management of heart failure (HF) with systolic dysfunction, widened QRS complex length, and New York Heart Association (NYHA) class III or IV. However, whether CRT is viable in HF patients who require inotropic support is still a matter of debate. To assess outcomes of CRT in end-stage inotrope-dependent HF. Following PRISMA guidelines, we searched Medline, EMBASE, Scopus, and Cochrane Library until December 31st 2021, with the following terms: “end-stage heart failure,” “catecholamine-dependent overt heart failure,” “inotrope-dependent heart failure,” “advanced heart failure,” “New York Heart Association class IV,” “NYHA class IV.” These terms were combined with “cardiac resynchronization therapy” OR “CRT” OR “biventricular device”. Studies were included if: 1) HF patients required on inotropic support at CRT implantation; 2) patients were at least 18 years old; and 3) provided a clear definition of “inotrope dependence” or “inability to wean.” A meta-analysis with random effects was performed in R (Version 3.5.1) with data presented as mean ± standard deviation. 9 studies comprised of 168 inotrope-dependent HF patients (mean age 64.4 ± 5.8 years, 79.6% male, 41.7% non-ischemic cardiomyopathy, mean QRS duration 173.9 ± 13.2 ms, 82.1% NYHA Class IV) were included for meta-analysis. Hospitalization rate for recurrence of HF 12-18 months post-CRT was 21% (95%CI: 15-28%, I2=0%, P=0.41, Fig 1C) and survival at 12 months post-CRT was 71% (95%CI: 58-83%, I2=68%, P<0.01, Fig 1D). A significant majority were weaned off inotropes at 93% (95%CI: 83-99%, I2=69%, P<0.01, Fig 1E) and 39% (95%CI: 19-61%, I2=69%, P<0.01, Fig 1H) improved to NYHA class II. A considerable proportion at 40% (95%CI: 15-68%, I2=88%, P<0.01, Fig 1G) improved to NYHA class III, but 12% (95%CI: 5-12%, I2=45%, P=0.09, Fig 1F) did not improve from NYHA class IV. Responders tended be male (85.7% vs. 40%, P=0.015, Table 1), have a history of left bundle branch block (71.4% vs. 30%, P=0.036, Table 1) or an increased left ventricular end-diastolic volume (274.3 mL vs. 225.9 mL, P=0.038, Table 1). Our findings suggest that CRT is a viable option for end-stage inotrope-dependent HF. Responders appear to be male with evidence of preserved diastolic function or a history of a left bundle branch block. Further work is necessary to optimize patient selection.Tabled 1Table 1 - Characteristics of Responders and Non-Responders to CRT. Data are presented as Mean ± Standard Deviation with percentages shown in brackets.FactorResponders to CRT (n=21)Non-Responders to CRT (n=10)p-valueMean Age (Years)65.5 ± 3.957.8 ± 5.80.412Males (%)18 (85.7)4 (40)0.015Hypertension (%)8 (38.1)2 (20)0.281Diabetes Mellitus (%)8 (38.1)2 (20)0.281Non-Ischemic Cardiomyopathy (%)18 (85.7)8 (80)0.528Atrial Fibrillation (%)8 (38.1)2 (20)0.281Left Bundle Branch Block (%)15 (71.4)3 (30)0.036Left Ventricular Ejection Fraction (%)19.5 ± 0.1524.1 ± 0.90.036Left Ventricular End-Systolic Volume (mL)218.2 ± 1.9175.5 ± 5.50.016Left Ventricular End-Diastolic Volume (mL)274.3 ± 7.2225.9 ± 6.10.038Pre-CRT QRS Length (ms)168.7 ± 8.4152.9 ± 6.10.298Post-CRT QRS Length (ms)156.7 ± 4.6149.7 ± 4.40.346 Open table in a new tab

Large animal preclinical investigation into the optimal extracorporeal life support configuration for pulmonary hypertension and right ventricular failure

Right ventricular failure (RVF) is a major cause of mortality in pulmonary hypertension (PH). Mechanical circulatory support holds promise for patients with medically refractory PH, but there are no clinical devices for long-term right ventricular (RV) support. Investigations into optimal device parameters and circuit configurations for PH-induced RVF (PH-RVF) are needed. Eleven sheep underwent previously published chronic PH model. We then evaluated a low-profile, ventricular assist device (VAD)-quality pump combined with a novel low-resistance membrane oxygenator (Pulmonary Assist Device, PAD) under one of four central cannulation strategies: right atrium-to-left atrium (RA-LA, N=3), RA-to-pulmonary artery (RA-PA, N=3), pumpless pulmonary artery-to-left atrium (PA-LA, N=2), and RA-to-ascending aorta (RA-Ao, N=3). Acute-on-chronic RVF (AoC RVF) was induced, and mechanical support was provided for up to 6 hours at blood flow rates of 1 to 3 liter/min. Circuit parameters, physiologic, hemodynamic, and echocardiography data were collected. The RA-LA configuration achieved blood flow of 3 liter/min. Meanwhile, RA-PA and RA-Ao faced challenges maintaining 3 liter/min of flow due to higher circuit afterload. Pumpless PA-LA was flow-limited due to anatomical limitations inherent to this animal model. RA-LA and RA-Ao demonstrated serial RV unloading with increasing circuit flow, while RA-PA did not. RA-LA also improved left ventricular (LV) and septal geometry by echocardiographic assessment and had the lowest inotropic dependence. RA-LA and RA-Ao configurations unload the RV, while RA-LA also lowers pump speed and inotropic requirements, and improves LV mechanics. RA-PA provide inferior support for PH-RVF, while an alternate animal model is needed to evaluate PA-LA.

Midodrine in treatment of post coronary revascularization vasoplagia; pilot, open label, assessor blinded randomized clinical trial

Abstract Purpose Post cardiac surgery hypotension and inotrope dependence are among major causes of prolonged intensive care unit (ICU) stay. Besides routine managements, catecholamine inotrope-vasopressors are the traditional treatment. However, there is an increasing interest to catecholamine-sparing agents, such as Midodrine, oral alfa1 agonist, in patients with vasoplegia. Up to now there are no randomized study with midodrine on post cardiac surgery patients. Material and method In this pilot, open label, assessor blind, randomized clinical trial from June 2020 to December 2021, 65 patients with refractory (more than 24 hours inotropes) hypotension after coronary revascularization were included. Patients were randomly assigned to receive Midodrine add-on therapy (10 mg stat and 5 mg po every 12 hours) or placebo add-on routine treatment. The primary outcome was liberation time from IV inotrope-support. Secondary outcomes were ICU admission time and total vasopressor dosage after randomization. Results 32 patients enrolled in Midodrine group, with a mean age of 60.72, and 33 patients received placebo with mean age of 63.27. Median liberation time from inotrope was 27 hours in Midodrine group and 49 hours in placebo group (p=0.022). ICU admission time for Midodrine and placebo groups were 115 and 121 hours, respectively (p=0.990). Total vasopressor dosage after randomization were similar in two studied groups, 4352 μg in Midodrine group and 5637 μg in placebo group (p=0.405). No adverse event was observed in Midodrine group. Conclusion Midodrine add-on inotrope therapy was a safe medication with appropriate compliance in ICU admitted patients after cardiac surgery, which seems to decrease the inotrope dependent time. Funding Acknowledgement Type of funding sources: None.

The impact of race on utilization of durable left ventricular assist device therapy in patients with advanced heart failure.

Heart failure affects >6 million people in the United States aloneand is most prevalent in Black patients who suffer the highest mortality risk. Yet prior studies have suggested that Black patients are less likely to receive advanced heart failure therapy. We hypothesized that Black patients would have decreased rates of durable left ventricular assist device (LVAD) implantation within our expansive heart failure program. A retrospective single-center cohort study was conducted at a single high-volume academic medical center. Patients between 18 and 85 years admitted with a diagnosis of cardiogenic shock or congestive heart failure between 1, 2013 and 12, 2017 with a left ventricular ejection fraction < 30% and inotropic dependence or need for mechanical circulatory support were included. Patients with contraindications to durable LVAD were excluded. An adjusted logistic regression model for durable LVAD implantation within 90 days of the index admission was used to determine the effect of race on durable LVAD implantation. Among the 702 study patients (60.9% White, 34.1% Black), durable LVAD implantation was performed within 90 days of the index admission in 183 (26%) of the cohort. After multivariate analysis, Black patients were not found to have a statistically significant difference in durable LVAD implantation rates compared to White patients in our study (OR: 0.68 [95%confidence interval: 0.45-1.04; p: .074]). Black patients in our study did not have a statistically significant difference in the rate of durable LVAD implantation compared with White patients after adjustments were made for age, sex, socioeconomic, and clinical covariates. Larger prospective studies are needed to validate these findings.

Impact of donor-to-recipient weight ratio on the hospital outcomes of pediatric heart transplantation

BackgroundIdentifying the factors that can influence the prognosis and final outcomes of pediatric heart transplantation is important and makes it possible to prevent complications and improve outcomes. Coordination of donor characteristics with the recipient in terms of sex, weight, body mass index (BMI), and body surface area (BSA) is an important factor that can influence the outcome of the transplantation. There is still no consensus regarding the role of discrepancy in anthropometrics between donors and recipients. The aim of this study was to investigate the relationship between donor and recipient weight mismatch on the early outcomes of pediatric heart transplantation. In this historical cohort study, 80 children who had underwent heart transplantation for the first time between 2014 and 2019 in Shahid Rajaie Cardiovascular Medical and Research Center in Tehran, Iran, were enrolled and divided into three groups according to donor-to-recipient weight ratio (0.8 < D/RW ≤ 1.5, 1.5 < D/RW ≤ 2.5, and 2.5 < D/RW). The early outcomes of transplantation, during the first post-transplant month, including right heart failure, renal failure, graft rejection, inotrope dependency, duration of intubation, length of ICU stay, death and requiring extracorporeal membrane oxygenation, were recorded through reviewing patient records.ResultsMedian donor-to-recipient BSA ratio was directly associated with higher vasoactive–inotropic score (P = 0.038), while no significant association was found between donor-to-recipient weight ratio and vasoactive–inotropic score (P = 0.07). No significant relationship was found between other outcomes and donor-to-recipient weight ratio or donor-to-recipient BSA ratio.ConclusionsPatients who require heart transplantation may also benefit from mismatch donors, especially in those with significant cardiomegaly.

When is Significant Left Ventricular Hypertrophy Acceptable for Donor Heart Selection

<h3>Purpose</h3> Extended criteria of donors for heart transplant (HTx) include many factors, such as left ventricular hypertrophy (LVH), decreased LVEF, older donor age, inotrope dependence, as well as gender and size mismatch. It has also been reported that various combinations of extended criteria risk factors appear to have worse outcomes depending on severity of the extended criteria characteristic. We sought to assess if severity of LVH with acceptable donor age and ischemic time is associated with increased mortality. <h3>Methods</h3> Between 2010 and 2020, we assessed 156 donor hearts with varying degrees of LVH defined as left ventricular septal thickness greater than 1.2 cm. Donor hearts were then divided into those that had IVS between 1.2 to <1.3 cm, 1.3 to <1.5 cm, ≥1.5 cm. In addition, an assessment was made for the same LVH groups versus donor age categorized as donor age ≥50 years old and donor ischemic time >240minutes. <h3>Results</h3> Severity of LVH with donor age <50 years and ischemic time <240 min appear to have acceptable 1-year survival. However, older donor age/long ischemic time with LVH are higher risk for 1-year mortality. (see table) <h3>Conclusion</h3> Severe LVH (IVS >1.5 cm) in donor hearts appears to be acceptable with donor age <50 years and ischemic time <240 minutes.

Large Animal Investigation of Cardiopulmonary Support for Acute-on-Chronic Right Ventricular Failure: Physiologic and Hemodynamic Consequences of Circuit Configuration

<h3>Purpose</h3> Right ventricular failure (RVF) is a major cause of mortality in pulmonary hypertension (PH) patients. Mechanical circulatory support holds promise for this population, but there are currently no clinical devices for long-term right ventricular (RV) support. Investigations into optimal device parameters and cannulation configurations for PH-induced RVF (PH-RVF) are needed. <h3>Methods</h3> We developed and evaluated a low-profile, ventricular assist device (VAD)-quality pump combined with a low-resistance membrane oxygenator, the Pulmonary Assist Device (PAD), for RV support in 11 sheep with chronic PH and RV hypertrophy. Four central cannulation configurations were evaluated: (1) right atrium-to-left atrium (RA-LA, N=3), (2) RA-to-pulmonary artery (RA-PA, N=3), (3) pumpless PA-to-LA (PA-LA, N=2), and (4) RA-ascending aorta (RA-Ao, N=3). Acute RVF was induced, and mechanical support was provided for up to 6 hours with blood flow rates of 1-3 L/min. Circuit, hemodynamic and echocardiographic data were collected. <h3>Results</h3> RA-LA achieved blood flow of 3 L/min within pump's operable speed, while RA-PA and RA-Ao were flow-limited due to higher circuit afterload. PA-LA could not achieve flow above 1 L/min. The oxygenator maintained a low resistance of <4 mmHg/L/min and provided oxygen delivery of 114 mL/min. RA-LA demonstrated serial RV unloading and lower inotropic dependence with increasing circuit flow. RA-Ao exhibited some RV unloading, but to a lesser extent compared to RA-LA. Meanwhile, the hemodynamic response was highly variable in RA-PA. In one trial of RA-PA, the circuit elicited severe pulmonary hemorrhage. Based on echocardiograms, only RA-LA preserved physiologic ventricular geometry. <h3>Conclusion</h3> RA-LA successfully unloads the RV at a lower pump speed, lower inotrope requirement, and improved LV filling compared to RA-Ao. RA-PA and pumpless PA-LA configurations were less viable as RV support in this study.

Right ventricular diastolic function predicts clinical atrial fibrillation after coronary artery bypass graft.

Background:Patients with moderate-severe left ventricular systolic dysfunction undergoing coronary artery bypass graft (CABG) surgery are at high risk of mortality and morbidity. Our aim is to evaluate the right ventricular (RV) diastolic function in these patients, and monitor its effects on postoperation outcomes.Materials and Methods:In a cohort study, patients with moderate-severe left ventricular systolic dysfunction (ejection fraction ≤35%) who were candidate for CABG were included. Baseline transthoracic echocardiography (TTE) was performed, and RV diastolic function measures were obtained. After CABG, the length of intubation, inotrope dependency, hospital stay in intensive care unit and ward, in-hospital and after discharge mortality, postoperative atrial fibrillation (POAF) were evaluated in all patients.Results:Sixty-seven patients were prospectively included in the study. The mean ± standard deviation age of our patients was 61.4 ± 9.3. There was no difference between grades of RV diastolic function and postoperative outcomes. However, we found significant difference between grades of RV diastolic function and onset of in hospital, and total POAF (P-value = 0.017). Multivariate analysis demonstrated that preoperative tricuspidEt/E’t (ratio of peak early-diastolic flow rate across the tricuspid valve orifice to peak early-diastolic velocity at the lateral tricuspid annulus), left atrial volume and “high risk” Euroscore II were independent predictors for POAF during hospitalization and total POAF in patients with moderate to severely impaired left ventricular systolic function (P-values were 0.04, 0.003 and 0.001, respectively).Conclusion:We believe that patients with increased tricuspid Et/E’t are high risk for POAF; therefore, any risk score for POAF should include a comprehensive TTE including evaluation of RV diastolic function before surgery.

Outcomes of Orthotopic Heart Transplantation in the Setting of Acute Kidney Injury and Renal Replacement Therapy

Heart transplantation in the setting of renal insufficiency is controversial. The objective of this study was to perform a descriptive analysis of patients who underwent orthotopic heart transplantation and renal replacement therapy (RRT) due to acute kidney injury (AKI). An observational cohort study with retrospective data collection. A tertiary care hospital. Fifty-one patients underwent orthotopic heart transplantation with cardiogenic shock under inotrope dependence, with nine patients having preoperative RRT and 42 patients not having preoperative RRT. There were no interventions. Hospital mortality occurred in eight (15.6%) patients. Although there were no significant differences between the study groups (preoperative RRT 33.3% v controls 11.9%, p=0.1), this study was underpowered to detect differences in mortality. Dialysis also was required in 52.4% of patients who were not on preoperative RRT. All survivors had full recovery of kidney function with similar timing after transplant (18.5 days v 15 days, p=0.75). Actuarial survival was 82.4%, 76.5%, and 66.5% at six months, one year, and five years, respectively. A cold ischemic time greater than 180 minutes (hazard ratio [HR] 4.37 95% confidence interval [CI] 1.51-12.6; p=0.006) and pretransplant RRT (HR=7.19 95% CI 1.13-45.7; p=0.04) were independent predictors of long-term mortality. In a health system with limited funding and availability of mechanical circulatory support, heart transplantation in the setting of AKI, RRT, and low Interagency Registry for Mechanically Assisted Circulatory Support profile was associated with important hospital mortality. Among hospital survivors, however, all patients had full renal recovery and by 25 months there was no difference in mortality between those who required preoperative RRT and those who did not.

Practices of Referring Patients to Advanced Heart Failure Centers

Therapies for advanced heart failure (AHF) improve the likelihood of survival in a growing population of patients with stage D heart failure (HF). Successful implementation of these therapies is dependent upon timely and appropriate referrals to AHF centers. We performed a retrospective analysis of patients referred to 9 AHF centers for evaluation for AHF therapies. Patients' demographics, referring providers' characteristics, referral circumstances, and evaluation outcomes were collected. The majority of referrals (n = 515) were male (73.4%), and a majority of those were in the advanced state of the disease: very low left ventricular ejection fraction (<20% in 51.5%); 59.4% inpatient; and high risk Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles (74.5% profile 1-3). HF cardiologists (49.1%) were the most common originating referral source; the least common (4.9%) were electrophysiologists. Common clinical triggers for referral included worsening HF (30.0%), inotrope dependence (19.6%), hospitalization (19.4%), and cardiogenic shock (17.8%). Most commonly, AHF therapies were not offered because patients were too sick (38.0%-45.1%) or for psychosocial reasons (20.3%-28.6%). Compared to non-HF cardiologists, patients referred by HF cardiologists were offered an AHF therapy more often (66.8% vs 58.4%, P = 0.0489). Of those not offered any AHF therapy, 28.4% received home inotropic therapy, and 14.5% were referred to hospice. In this multicenter review of AHF referrals, HF cardiologists referred the most patients despite being a relatively small proportion of the overall clinician population. Late referral was prevalent in this high-risk patient population and correlates with worsened outcomes, suggesting a significant need for broad clinician education regarding the benefits, triggers and appropriate timing of referral to AHF centers for optimal patient outcomes.

Discordance between lactic acidemia and hemodynamics in patients with advanced heart failure.

BackgroundElevated lactic acid (LA) levels carry a poor prognosis in patients with shock. Data are lacking on the significance of LA levels in patients with acute decompensated heart failure (ADHF).HypothesisThis study assessed the relationship between LA levels, hemodynamics and clinical outcomes.MethodsThis was a retrospective analysis of registry data of 100 advanced heart failure patients presenting for right heart catheterization (RHC) for concern of ADHF. LA levels (normal 2.1 mmol/L) were obtained prior to RHC; no significant changes in therapy were made between LA collection and RHC.ResultsMedian age was 58 (47.3, 64.8) years; 57% were receiving inotropes prior to RHC. Median pulmonary capillary wedge pressure (PCWP) and cardiac index (CI) were 28 (21, 35) mmHg and 2.0 (1.7, 2.5) L/min/m2, respectively. Eighty patients had normal LA prior to RHC. There was no correlation between LA levels and PCWP (R = 0.09, p = .38); 63% of the normal LA group had a PCWP 24 mmHg. There was a moderate inverse correlation between LA and CI (R = − 0.40; p < .001); 58% of the normal LA group had a CI <2.2 L/min/m2. Thirty‐day survival free of death/hospice, inotrope dependence, progression to heart transplant/left‐ventricular assist device implant was comparable between the normal and elevated LA groups (28% vs. 20%; p = .17).ConclusionIn patients presenting with ADHF, normal LA levels do not exclude the presence of depressed CI (a hemodynamic criteria for cardiogenic shock) and may not offer accurate risk stratification. Invasive hemodynamics should not be delayed based on normal LA levels alone.

Right atrium to pulmonary capillary wedge pressure ratio is associated with right ventricular failure and mortality after left ventricular assist device surgery

Abstract Introduction Right ventricular failure (RVF) is a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. We investigated the role of right atrium to pulmonary capillary wedge pressure (RA/PCWP) ratio as a preoperative predictor of postoperative RVF after LVAD surgery. Methods A retrospective analysis of all consecutive patients who received continuous-flow LVADs (HeartMate 2, 3, and HVAD) between August 2012 and May 2018 in a single tertiary center. INTERMACS profile 1 patients were excluded. RA/PCWP ratio was calculated for the entire cohort and divided into quartiles (Q). Patients were stratified into high (Q4) vs. low (Q1–3) RA/PCWP ratio. The primary end point was the composite of in hospital mortality and RVF (defined as the need for a right ventricular assist device or inotrope dependence for &amp;gt;7 days). The secondary endpoint was readmission within 14 days after discharge. Results The study cohort consisted of 59 patients (15 patients in the high RA/PCWP group and 44 patients in the low RA/PCWP group) with a median follow-up of 21 months (Interquartile range 14–31). The mean age was 56±11 years and the majority of patients were male (88%). Patients were classified as INTERMACS profile 2 (34%), 3 (19%) or 4 (47%). Preoperative clinical, laboratory, and echocardiographic parameters were similar in both groups except for a larger proportion of patients with a dilated right ventricle and above moderate tricuspid regurgitation in the high compared to the low RA/PCWP group (73% vs. 29%; P=0.006 and 40% vs. 2%; P=0.001, respectively). Overall, 7 patients (12%) developed the primary end-point and 9 patients (15%) developed the secondary end-point. Univariate analysis demonstrated that high RA/PCWP is associated with both primary and secondary end-points (odds ratio [OR], 7.6; 95% confidence interval [CI] 1.2–47.2, P=0.029 and OR, 6.25; 95% CI 1.3–28.5, P=0.018, respectively). On multivariable analysis, the association remained significant after adjustment for INTERMACS score (OR, 10.6; 95% CI 1.4–80.9, P=0.022 and OR, 7.9; 95% CI 1.5–42.2, P=0.015, respectively). Using receiver operating characteristic curve (ROC) derived cut-points, RA/PCWP &amp;gt;0.57 provided 67% sensitivity and 79% specificity (C-statistic = 0.73) for the prediction of in hospital mortality and RVF and 56% sensitivity and 84% specificity (C-statistic = 0.69) for the prediction of readmissions within 14 days after discharge. In comparison, in our cohort using ROC-derived cut points, pulmonary artery pulsatility index, an established RVF predictor, of less than 1.84 provided 40% sensitivity and 20% specificity (C-statistic = 0.3) for the prediction of inhospital death and RVF. Conclusion RA/PCWP ratio may help to identify patients at high risk of developing adverse clinical outcomes, including RVF and mortality, after LVAD surgery. Funding Acknowledgement Type of funding source: None

A medical epopee: recurrent fungal endocarditis, heart transplantation and chylopericardium

BackgroundCandida prosthetic endocarditis is associated with high mortality rates and valve replacement surgery, together with antifungal treatment, play a major role in eradicating the fungal infection.Valve reoperations in these scenarios may be relatively common due to the high infection relapse rates and, in some cases, heart transplantation may be an imposing therapy for infection resolution and for the heart failure related to the myocardial reoperation injury. Among the many postoperative complications related to heart transplantation, chylopericardium is a rare but challenging example.Case presentationWe report the case of a 55-year-old man who was admitted to our hospital with a 1-month history of progressive dyspnea and fatigue. His past medical history included four open-heart surgeries for aortic and mitral valve replacement due to recurrent Candida parapsilosis infective endocarditis. Transthoracic echocardiogram showed a markedly reduced left ventricular systolic function and normofunctioning bioprosthetic valves. An inotropic dependency condition led to heart transplantation surgery. In the early postoperative period, a persistent chylous fluid started to drain from the pericardial tube, compatible with the diagnosis of chylopericardium. The lack of clinical response to total parenteral nutrition and intravenous infusion of octreotide imposed the need of interventional radiology with diagnostic lymphography through cisterna chyli puncture and thoracic duct catheterization, confirming the presence of a lymphatic fistula. A successful treatment outcome was achieved with percutaneous thoracic duct embolization using coils and n-butyl-cyanoacrilate glue, possibiliting hospital discharge.ConclusionsFungal endocarditis requires combined treatment (surgical and antimicrobial) for eradication. Valve replacement, while necessary, may lead to severe ventricular deterioration and heart transplantation may be the only viable therapeutic solution. Among the several postoperative complications of heart transplantation, chylopericardium is an uncommon and defiant example. Advances in interventional radiology like the percutaneous embolization allow a less invasive and highly efficient approach for this complication.

Primary Caregiver Relationships for Advanced Heart Failure Therapy Differ Based on Sex and Race and Predict Eligibility

Introduction Use of heart transplant (HT) and left ventricular assist device (LVAD) are considered standard of care for eligible patients with end-stage heart failure (HF). In assessing eligibility, caregiver assistance is an important consideration in a patient's candidacy. While studies have shown that individuals without caregivers have worse survival outcomes, few studies have demonstrated how caregiver relationships differ based on sex and race, and whether that impacts eligibility for HT/LVAD. Hypothesis Women and Black patients are less likely than men and non-Black patients, respectively, to have a spouse listed as primary support, which may adversely affect eligibility for HT/LVAD. Methods We identified all patients (N=534) evaluated at Emory University for HT/LVAD from 2011 to 2016. Stanford Integrated Psychological Assessment for Transplant (SIPAT) scores were compared by sex and race using Wilcoxon rank-sum tests. The outcome of HT/LVAD evaluation according to primary caregiver relationship was compared by sex and race using X2 analysis. Multivariable logistic regression was used to determine the association between primary caregiver and HT/LVAD eligibility according to sex and race, adjusted for age, HF etiology, insurance, inotrope dependence, bilirubin, albumin, allosensitization, CKD stage, and SIPAT score. Results The mean age of the cohort was 52 ± 13 years; 171 (32%) were women and 294 (55%) were black. Total SIPAT scores did not vary significantly between men and women or blacks and non-blacks, regardless of primary support person. Women were less likely to have a spouse as primary support, and were more likely to have a parent or child as primary support (Table). Black patients were less likely to have a spouse as primary support, and were more likely to have a parent as primary support. In sex-stratified multivariable models, the choice of primary caregiver did not affect eligibility for HT/LVAD for women (P=0.8) or men (P=0.4). In race-stratified multivariable models, blacks with a parent as primary caregiver were less likely to be eligible for HT/LVAD (OR=0.17, 95% CI 0.03 - 0.97, P=0.04), however the primary caregiver was not associated with eligibility for HT/LVAD in non-black patients (P=0.9). Conclusion The choice of primary support person has a modest effect on decreasing eligibility for black patients being evaluated for advanced HF therapies, but not for women. More research is needed to determine unique barriers to advanced HF therapies for female and black patients.

Association between high dose catecholamine support and liver dysfunction following cardiac surgery.

Cardiac surgery using cardiopulmonary bypass is a well-established procedure. However, up to 20% to 30% of patients require high dose vasopressor or inotropic support following surgery, enhancing the risk of organ dysfunction and impacting mortality. Nonalcoholic fatty liver disease (NAFLD) is a frequent finding in these patients and may be involved in the pathophysiology of vasoplegia and cardiac failure. Retrospective analysis of 463 patients undergoing elective cardiac surgery in 2014 at our institution. NAFLD was defined using the NAFLD fibrosis score and the vasoactive-inotropy score was used to determine postoperative vasopressor and inotropic dependency. Patients with NAFLD more often presented with high vasopressor or inotropic support compared to patients without NAFLD, resulting in significant differences after 6 hours (n = 20 [27.0%] of 74 patients), 12 hours (n = 20 [27.0%] of 74 patients), and on the first postoperative day (n = 12 [16.4%] of 73 patients) of intensive care unit (ICU) treatment. Multivariate analysis revealed time of catecholamine application (P = .001), preoperative left ventricular ejection fraction (P = .001), type of surgery (P = .001), model of endstage liver disease on hospital admission (P = .002), pre-existing pulmonary hypertension (P = .004) and NAFLD-time interaction (P = .05) as independent predictors of high vasopressor and inotropic support. Patients with NAFLD had higher degrees of extrahepatic organ dysfunction, were more dependent on hemodialysis, spent more days in the ICU and within the hospital. Patients with NAFLD and high catecholamine support had the highest mortality rates among the study population. NAFLD is a common finding in elective cardiac surgery patients. Anesthesiologists and intensivists should be sensitive for the specific risk profile of this population.

Cardiac Power Efficiency as a Hemodynamic Predictor of Outcomes in Congestive Heart Failure

Cardiac power index (CPI) has been used as a predictor of outcomes in cardiogenic shock. Cardiac power efficiency (CPE), which is the CPI divided by the PCWP, has been used successfully to predict response to a durable counterpulsation MCS device. The aim of this study is to evaluate the utility of CPE in predicting outcomes in advanced heart failure patients presenting with decompensation. This is a single institution, retrospective review of 128 advanced heart failure patients who presented with decompensation. A right heart catheterization was performed upon admission. Patients were separated into two groups: those who survived 30 days and were only on optimal medical therapy and those who experienced "cardiac failure", including death, hospice, transplantation, LVAD implantation, or inotrope dependence. Statistical analysis included multivariate regression controlling for age, race, sex, BMI, BNP, heart failure etiology, ejection fraction, acute or chronic heart failure, and GFR. In this 128 patient cohort, 83 (64.8%) progressed to "cardiac failure". Multiple hemodynamic parameters were statistically significant between the two groups (Table 1). Multivariate regression showed CPE (p=0.006) was the only significant predictor of "cardiac failure". CPI (p=0.052) was not significant when used in the regression model. Sensitivity analysis was performed at multiple CPE cutoffs and the highest sensitivity (75.3%) was obtain at a CPE cutoff of 0.0178. Cardiac power efficiency is a novel hemodynamic parameter which has the potential to identify patients in cardiogenic shock who will not survive with medical therapy alone. Larger studies are needed to better identify CPE cutoffs which predict greatest risk.

Cardiac Reserve as Assessed by Augmentation in Cardiac Power Efficiency Predicts Response to Intravascular Ventricular Assist System Support

The intravascular ventricular assist system (iVAS) is a durable, ambulatory counterpulsation device that is currently under investigation for advanced heart failure patients. Baseline cardiac power efficiency (CPE) has previously been reported to predict hemodynamic success after iVAS. We investigated the role of change in CPE after inotropic challenge, a marker of cardiac reserve, as a prognostic tool prior to iVAS support. Hemodynamic data at the time of right heart catheterization was collected on patients just prior to iVAS implantation. A subset of patients underwent milrinone loading followed by repeat hemodynamic assessment 10 min after a 50 mcg/kg milrinone infusion. Cardiac power index (CPI) was calculated as [CPI = cardiac index (CI) x mean arterial pressure (MAP)/451)] and CPE was calculated as [CPE = CPI/Pulmonary capillary wedge pressure (PCWP)]. CPE at baseline and after inotropic challenge was calculated and a percent augmentation of 25% or greater in CPE was used as a cutoff indicative of cardiac reserve. The combined endpoint of independently adjudicated heart failure events, dependency on inotropes 7 days after implant, need for escalation to ECMO or death was evaluated. 40 patients from a single institution underwent iVAS implantation. 39 patients underwent RHC prior to iVAS (11.7 +/- 14.0 days before surgery). 11 patients underwent milrinone loading followed by repeat hemodynamic assessment. Baseline hemodynamics revealed an average CPE of 0.0227 +/- 0.0148 watts*mmHg/m2 for the entire cohort. In the subset of patients who underwent milrinone loading, CPE increased on average 41% from 0.0141 +/- 0.0055 watts*mmHg/m2 to 0.0236 +/- 0.0114 watts*mmHg/m2 (p = 0.003). There was a trend towards freedom from death, ECMO, HF events, or inotrope dependency in those who were able to augment CPE by more than 25% (N = 8), compared to those with less (N = 3) cardiac reserve OR = 0.071 (95% CI 0.003 - 1.73, p = 0.105). Cardiac reserve as defined as a greater than 25% augmentation in CPE after milrinone challenge may predict future success with counterpulsation with iVAS. This hypothesis generating question warrants further investigation.