Treatment Of Advanced Heart Failure Research Articles

Cardiac Contractility Monitoring: an Important Therapy in the Treatment of Advanced Heart Failure.

This review highlights the mechanisms of action of cardiac contractility modulation (CCM) and the clinical data which supports its use for the appropriate patient population. CCM has beneficial effects on myocardial calcium handling and reverse remodeling of abnormal genetic programs. Clinical trials show sustained improvements in quality of life, exercise tolerance, and heart failure symptoms. Heart failure is a global epidemic that is expected to increase in prevalence over the coming years. Despite improvements in, and the standardization of, optimal medical therapy (OMT), morbidity and mortality remain unacceptably high, with a 5-year mortality rate of 50%. While more recent advances in device therapies, including chronic resynchronization therapy (CRT), and left ventricular assist devices (LVADs), have changed the care of advanced heart failure for a certain subset of patients, there remains a therapeutic gap in the treatment of patients with heart failure and reduced ejection fraction (HFrEF) who are not candidates for CRT. CCM is a novel device-based therapy which delivers an electrical stimulus during the absolute refractory period and has been shown to improve heart failure symptoms, exercise tolerance, and quality of life.

Longitudinal Effects of Left Ventricular Assist Device Implantation on Global and Domain-Specific Cognitive Function.

Left ventricular assist devices (LVADs) are a common treatment of advanced heart failure, but cognitive dysfunction, which is common in heart failure, could limit the ability to perform postimplantation LVAD care. Implantation of an LVAD has been associated with improved cerebral perfusion and may improve cognitive function post implantation. The aim of this study was to quantify longitudinal change in cognitive function after LVAD implantation. A secondary analysis of data on 101 adults was completed to evaluate cognitive function before implantation and again at 1, 3, and 6 months post implantation of an LVAD. Latent growth curve modeling was conducted to characterize change over time. Serial versions of the Montreal Cognitive Assessment were used to measure overall (total) cognitive function and function in 6 cognitive domains. There was moderate, nonlinear improvement from preimplantation to 6 months post implantation in Montreal Cognitive Assessment total score (Hedges' g = 0.50) and in short-term memory (Hedges' g = 0.64). There also were small, nonlinear improvements in visuospatial ability, executive function, and attention from preimplantation to 6 months post implantation (Hedges' g = 0.20-0.28). The greatest improvements were observed in the first 3 months after implantation and were followed by smaller, sustained improvements or no additional significant change. Implantation of an LVAD is associated with significant, nonlinear improvement in short-term memory and global cognitive function, with the most significant improvements occurring in the first 3 months after implantation. Clinicians should anticipate improvements in cognitive function after LVAD implantation and modify postimplantation education to maximize effectiveness of LVAD self-care.

P1173Interlead electrical delay time as early predictor of the reverse myocardial remodeling in modern CRT devices

Abstract Funding Acknowledgements Russian Science Foundation Grant №19-14-00134 Background Cardiac resynchronization therapy (CRT) has undoubtedly shown a high role in the treatment of advanced heart failure (HF). Despite the quadripolar left ventricle (LV) lead widespread use, the problem of low response to CRT remains actual. The search for predictors of the CRT response is an important scientific and practical task. The aim To determine the relationship between the interlead electrical delay time and the CRT response during 12 month observational period. Materials and methods We evaluated the clinical status, the quality of life and echocardiographic response of 50 patients with HF treated for 1 year with quadripolar LV lead CRT devices implanted according to guidelines: 35 males/15 females with age 62.78 ± 11.58 years, 28 pts with history of ischemic cardiac disease, LVEF 27.42 ± 9.56%; QRS duration 157.34 ± 19.76 ms. The response to CRT was defined as 15% decrease of end-systolic left ventricle (LV) volume (LVESV), 10% relative increase of LV ejection fraction (LVEF), an improvement of at least 1 NYHA HF functional class. Interlead electrical delay time (EDT) was calculated automatically during CRT implantation, and subsequent 3-6-12 month FU. EDT values from 4 LV lead poles were evaluated according to LV sizes, volumes and LVEF. Results It was shown that the greater EDT value, the more pronounced was response to CRT. The first difference in EDT is observed after 6-month observational period. The EDT difference was determined using the delta formula for equalize. In 21 patients in whom the stimulation of the LV lead was carried out from a pole having a maximum EDT value, the response to CRT was observed earlier - at 6 months FU (24 pts with maximum EDT value vs. other 26 pts). In addition, the echocardiographic data of reverse myocardial remodeling (LVESD, LVEDD, LVESV, LVEDV and LVEF) correlated with a gradual decrease in the EDT values, r = 0.49, P = 0.008. There were no differences between the HF etiology (ischemic/ non-ischemic) and baseline rhythm. The mean EDT was initially 104.94 ± 44.22 ms, 6 month FU 98.91 ± 34.28 ms, 12 month FU 91.84 ± 32.78 ms. Conclusion The interlead electrical delay time in quadripolar CRT devices depends on reverse myocardial remodeling. EDT gradual decrease may be a predictor of the response to CRT. Abstract Figure. Interlead Delay Time 12M Follow Up

Levosimendan Can Improve the Level of B-Type Natriuretic Peptide and the Left Ventricular Ejection Fraction of Patients with Advanced Heart Failure: A Meta-analysis of Randomized Controlled Trials.

Levosimendan, a calcium (Ca2+)-sensitizing cardiotonic agent, is mainly used in patients with advanced heart failure. However, no research could explain how levosimendan reduces the mortality in advanced heart failure patients. We aim to illustrate the efficacy of levosimendan through clinical indexes. We searched PubMed, Embase, and CENTRAL from 1994 to August 2019 to compare the efficacy of levosimendan infusion for the treatment of advanced heart failure with that of other agents (placebo, dobutamine, furosemide, and prostaglandin E1). Levels of B-type natriuretic peptide (BNP) and N-terminal pro BNP (NT-proBNP), and left ventricular ejection fraction (LVEF) and heart rate (HR) were analyzed. The count data were analyzed by the standardized mean difference (SMD) and its 95% confidence interval (CI) to determine the effect size. We chose the random effect model or the fixed effect model according to the heterogeneity. Nine randomized controlled trials with 413 patients were ultimately enrolled. Compared with other agents (placebo, dobutamine, furosemide, and prostaglandin E1), levosimendan significantly reduced the BNP level (SMD -0.91; 95% CI -1.44 to -0.39; p = 0.001; I2 = 74.3%) and improved the LVEF (SMD 0.74; 95% CI 0.22-1.25; p = 0.005; I2 = 79.7%). However, levosimendan did not significantly change the HR (SMD0.09; 95% CI -0.24 to 0.42; p = 0.592; I2 = 51.5%). Meanwhile, we found that the main source of heterogeneity was the use of loaded or unloaded levosimendan. Our meta-analysis suggests that intravenous levosimendan can reduce BNP level and increase LVEF in patients with advanced heart failure to reduce the mortality at the shortest follow-up available.

Old and New Drugs for Treatment of Advanced Heart Failure.

Advanced heart failure (HF) is a progressive disease with high mortality and limited medical therapeutic options. Long-term mechanical circulatory support and heart transplantation remain goldstandard treatments for these patients; however, access to these therapies is limited by the advanced age and multiple comorbidities of affected patients, as well as by the limited number of organs available. Traditional and new drugs available for the treatment of advanced HF have been researched. To date, the cornerstone for the treatment of patients with advanced HF remains water restriction, intravenous loop diuretic therapy and inotropic support. However, many patients with advanced HF experience loop diuretics resistance and alternative therapeutic strategies to overcome this problem have been developed, including sequential nephron blockade or use of the hypertonic saline solution in combination with high-doses of furosemide. As classic inotropes augment myocardial oxygen consumption, new promising drugs have been introduced, including levosimendan, istaroxime and omecamtiv mecarbil. However, pharmacological agents still remain mainly short-term or palliative options in patients with acute decompensation or excluded from mechanical therapy. Traditional drugs, especially when administered in combination, and new medicaments represent important therapeutic options in advanced HF. However, their impact on prognosis remains unclear. Large trials are necessary to clarify their therapeutic potential and prognostic role in these fragile patients.

Quadritherapy vs standard tritherapy immunosuppressant regimen after heart transplantation: A propensity score-matched cohort analysis.

After heart transplant, adding everolimus (EVL) to standard immunosuppressive regimen mostly relies on converting calcineurin inhibitors (CNIs) into EVL. The aim of this study was to describe the effects of combining low-dose EVL and CNIs in maintenance immunosuppression regimen (quadritherapy) and compare it with standard tritherapy associating standard-dose CNIs, mycophenolate mofetil, and corticosteroids. In the 3-year registry cohort of heart transplanted patients, those who received quadritherapy were compared with those who received tritherapy. EVL was added after 3months posttransplant. Three analyses were performed to control for confounders: propensity score matching, multivariable survival, and inverse probability score weighting analyses. Among 213 patients who were included (75 with quadritherapy), propensity score matching selected 64 unique pairs of patients with similar characteristics. In the matched cohort (n=128), quadritherapy was associated with fewer deaths (3 [4.7%] vs 17 [21.9%], P=.007) and biopsy-proven acute rejections (15 [23.4%] vs 31 [48.4%], P=.002). These results were confirmed in the overall cohort (n=213), after multivariable and inverse probability score weighting analyses. Renal function and donor-specific HLA-antibodies remained similar in both groups. Low-dose combination quadritherapy was associated with fewer deaths and rejections, compared with standard immunosuppression tritherapy.

A Clinical Study to Evaluate Ambulatory Counterpulsation for the Treatment of Advanced Heart Failure: A Feasibility Study

This is a single-arm, non-randomized study designed to assess the preliminary safety and clinical performance of a novel ambulatory counterpulsation device. The device is an intra-aortic, counterpulsation blood pump delivered via axillary artery. The system includes a skin interface device facilitating patient ambulation and an external, portable drive unit allowing increased mobility and independence. This study will assess potential benefits to patients who have advanced heart failure and require additional circulatory support. This study will evaluate human factors, the clinical safety of the device, device failures, whether the device performs its intended purpose, patient characteristics that may impact device performance, and device use outside of the hospital. Following a First-in-Human study of 14 patients, this feasibility study will enroll up to 86 implanted patients in up to 20 investigational sites for a total of 100 patients on device. To date, 71 of 100 patients have been implanted across 14 of 16 participating institutions. The primary endpoint of this study is to assess survival to transplant or stroke-free survival at 30 days. The following secondary endpoints will also be evaluated at 30 days: number of patients who deteriorate requiring escalation of inotropic support and/or additional mechanical circulatory support; incidence of serious device-related adverse events; incidence of procedure-related adverse events; incidence of all adverse events; change in NYHA class from baseline; change in quality of life from baseline as measured by Kansas City Cardiomyopathy Questionnaire (KCCQ) - global assessment; change in Seattle Heart Failure Model Prognosis Score; change in six minute walk test and two minute step test from baseline. Subjects supported with the device past 30 days will continue to be followed and evaluated in the study until transplantation, device explant, alternative mechanical circulatory support or death. A Pivotal Trial with this device is expected to begin by the second quarter of 2020.

Pharmacological Treatment of Pump-Related Thrombosis in Patients with Left Ventricular Assist Device (HearWare HVAD)

Left ventricular assist device (LVAD) is one of the stablished treatments for advanced heart failure. Pump thrombosis (PT) is a major complication, increasing morbidity and mortality in LVAD patients. PT management includes surgical and pharmacological measures but the optimal treatment is not well defined. For this purpose, we reviewed our experience. From June 2011 to July 2019, 85 patients were implanted with a third generation LVAD (HeartWare HVAD, Medtronic, Inc.). All patients were implanted as a Bridge to Transplantation (BTT). PT was considered using INTERMACS criteria. Pharmacological treatment was defined by the use of intravenous heparin alone or in association with systemic thrombolysis with tissue plasminogen activator, t-PA-Actiliyse or with left intraventricular thrombolysis with t-PA-Actilyse. Success of the treatment was defined as improvement on biological and/or LVAD parameters, no surgical pump exchange and survival at 30 days. Treatment complications were defined as ischemic or hemorrhagicstroke or fatal bleeding. There were 47 pump thrombosis in 15 patients (18.3%, 12 men) for a total event rate of 3.1 thrombosis/patient. The mean time for all thrombotic event was 100.2±134.23 months and mean time for the first thrombotic event for heparin alone, local fibrinolysis and systemic fibrinolysis was 85.7, 40.1 and 174.8 months respectively.Thirteen thrombotic events were treated with systemic heparin alone, 26 were treated with systemic thrombolysis and 8 were treated with left intraventricular thrombolysis. Pharmacological treatment was successful in 13 patients, two patients died (intraventricular thrombolysis): one from stroke hemorrhage and one from abdominal hemorrhage. 12 patients were successfully transplanted. One patient is still alive with the LVAD. The mean waiting time on the transplant list was 35.3±18.1 months after PT. The 30 days survival is not statistically significant between the different pharmacological treatments for pump thrombosis. LVAD thrombosis is a major complication after LVAD implantation. Pharmacological conservative treatment with heparin or fibrinolysis could be the first line treatment before considering pump exchange or urgent heart transplant.

MAGGIC-Predicted Mortality of >20% at One Year is Associated with Poor Prognosis in Ambulatory Patients with Advanced Heart Failure

The MAGGIC score might help select patients who would gain prognostic benefit from heart transplantation or mechanical circulatory support (MCS). We examined the association between MAGGIC predicted prognosis and actual outcomes, in order to assess predictive performance of the score and determine a threshold for identifying patients at risk. We included 702 consecutive outpatients who were assessed for heart transplantation over ten years. The MAGGIC score was calculated for each patient according to the scoring matrix and patients were stratified into quartiles. The co-primary endpoints were death, urgent heart transplantation or need for MCS. Follow up was censored at routine heart transplantation. Kaplan-Meier curves were constructed and calibration testing was performed. 320 (45.6%) patients reached a primary endpoint during a median follow-up of 547 days. MAGGIC-predicted mortality was associated with event-free survival (figure, log rank P<0.0001). The MAGGIC score was well-calibrated at one year but over-estimated event-free survival at three years. 92 (13.1%) of patients had a MAGGIC-predicted one year mortality of >20% and these patients had the worst outcomes. At this threshold, the MAGGIC score had high specificity (93.5%) but low sensitivity (20.9%), giving a positive likelihood ratio of 3.22 for death, urgent heart transplantation or the need for MCS. MAGGIC-predicted mortality is associated with real world outcomes in ambulatory patients with advanced heart failure. Clinicians should not be reassured by low MAGGIC-predicted mortality because sensitivity is poor and event-free survival at three years is lower than predicted. However, high MAGGIC-predicted mortality (>20% at one year) is a specific marker of very poor outcomes and may be used to select patients who might derive prognostic benefit from surgical treatment of advanced heart failure, such as implantation of a left ventricular assist device.

Does Age at The Time of LVAD Implantation Affect Post LVAD Implantation Survival? A Single Center Experience

Use of left ventricular assist device (LVAD) therapy is proven to be effective for the treatment of advanced heart failure. Heart transplant is not an option for patients with advanced age, frequently defined as age 70 or greater. The purpose of this study was to compare the survival rate post LVAD implantation for between patients who were less than 70 years or 70 years or older. A retrospective review of patients implanted with an LVAD between March 2008 and February 2019 was conducted. 413 patients who received a continuous flow LVAD were included in the study. Patients were stratified by ≥70 years of age (n= 60) and <70 years of age (n=357). The post-implant survival time frames reviewed were 6 months, 1 year, and 2 years. The patients included in the study were implanted with a variety of LVADs, including Levacor, HeartMate 2, HeartMate 3, and HVAD devices. The overall survival rate was based on the Kaplan-Meier estimates and the Log-Rank test was used to compare the survival curves of the two groups. Table 1 contains baseline demographics and survival. There was no statistically significant survival difference between the two groups. Survival in the 18-69 group vs the ≥70 group at 6 months was 87.8% vs 83.3% (p 0.302). 1 year survival was 81.6% and 83.3% (p 0.793), and 2 year survival was 70.3% and 71.7% (p 0.629), respectively. Figure 1 shows the Kaplan-Meier curves for each group. LVAD recipients who were ≥70 years of age did not experience increased mortality compared to LVAD recipients who were 18-69 years of age. Patients should not be declined for LVAD therapy based on chronological age alone.

Neutrophil to Lymphocyte Ratio Is Related to Thrombotic Complications and Survival in Continuous Flow Left Ventricular Assist Devices.

Left ventricular assist devices (LVADs) have become an established treatment for advanced heart failure, although with long-term support these patients are potentially exposed to serious complications. Our purpose was to assess the role of the neutrophil to lymphocyte ratio (NLR) in LVAD complications and to evaluate if higher values of NLR after 4-6 months on LVAD support (NLR 4_6m) are associated with worse prognosis. All consecutive patients who received a HeartWare LVAD (N = 188, age 50 ± 13 years), as bridge to transplant from December 2009 to January 2018 were included. Neutrophil to lymphocyte ratio was recorded pre-LVAD, post-LVAD, after 4-6 months on support and in case of a first adverse event to occur after the 4-6 months NLR was recorded. Median NLR values were pre-LVAD 4.26 (interquartile range [IQR], 3.1-6.9), at 1 day postoperative 11.6 (IQR, 8.3-16.6), and NLR 4_6m 4.4 (IQR, 3.0-6.4) (p < 0.001). Neutrophil to lymphocyte ratio increased significantly when patients had an infection, stroke, or pump thrombosis, as compared with the NLR 4_6m (all p < 0.05). Patients with NLR 4_6m ≥ median had higher rates of stroke and mortality. Survival time was shorter among patients with NLR 4_6m ≥ 4.4 (log-rank test p = 0.006). Neutrophil to lymphocyte ratio 4_6m was found to be predictive of increased mortality (area under the curve of 0.62, p = 0.007). After multivariate analysis, NLR 4_6m remained independently associated with increased mortality (hazard ratio [HR] 1.67; 95% confidence interval [CI], 1.03-2.7; p = 0.037). Neutrophil to lymphocyte ratio 4_6m values significantly increase in association with adverse events on LVAD support and are independently associated with mortality. This association suggests presence of inflammation adversely affects LVAD outcomes.

Association of Clinical Outcomes With Left Ventricular Assist Device Use by Bridge to Transplant or Destination Therapy Intent

Left ventricular assist devices (LVADs) are well established in the treatment of advanced heart failure, but it is unclear whether outcomes are different based on the intended goal of therapy in patients who are eligible vs ineligible for heart transplant. To determine whether clinical outcomes in the Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3 (MOMENTUM 3) trial differed by preoperative categories of bridge to transplant (BTT) or bridge to transplant candidacy (BTC) vs destination therapy (DT). This study was a prespecified secondary analysis of the MOMENTUM 3 trial, a multicenter randomized clinical trial comparing the magnetically levitated centrifugal-flow HeartMate 3 (HM3) LVAD to the axial-flow HeartMate II (HMII) pump. It was conducted in 69 centers with expertise in managing patients with advanced heart failure in the United States. Patients with advanced heart failure were randomized to an LVAD, irrespective of the intended goal of therapy (BTT/BTC or DT). The primary end point was survival free of disabling stroke or reoperation to remove or replace a malfunctioning device at 2 years. Secondary end points included adverse events, functional status, and quality of life. Of the 1020 patients with implants (515 with HM3 devices [50.5%] and 505 with HMII devices [49.5%]), 396 (38.8%) were in the BTT/BTC group (mean [SD] age, 55 [12] years; 310 men [78.3%]) and 624 (61.2%) in the DT group (mean [SD] age, 63 [12] years; 513 men [82.2%]). Of the patients initially deemed as transplant ineligible, 84 of 624 patients (13.5%) underwent heart transplant within 2 years of LVAD implant. In the primary end point analysis, HM3 use was superior to HMII use in patients in the BTT/BTC group (76.8% vs 67.3% for survival free of disabling stroke and reoperation; hazard ratio, 0.62 [95% CI, 0.40-0.94]; log-rank P = .02) and patients in the DT group (73.2% vs 58.7%; hazard ratio, 0.61 [95% CI, 0.46-0.81]; log-rank P < .001). For patients in both BTT/BTC and DT groups, there were not significantly different reductions in rates of pump thrombosis, stroke, and gastrointestinal bleeding with HM3 use relative to HMII use. Improvements in quality of life and functional capacity for either pump were not significantly different regardless of preimplant strategy. In this trial, the superior treatment effect of HM3 over HMII was similar for patients in the BTT/BTC or DT groups. It is possible that use of arbitrary categorizations based on current or future transplant eligibility should be clinically abandoned in favor of a single preimplant strategy: to extend the survival and improve the quality of life of patients with medically refractory heart failure. ClinicalTrials.gov identifier: NCT02224755.

Anaerobic Bacteremias in Left Ventricular Assist Devices and Advanced Heart Failure

Left ventricular assisted devices (LVADs) have revolutionized the treatment of advanced heart failure, providing meaningful increases in survival, functional capacity, and quality of life. There are two categories of LVADs patients: (1) bridge-to-transplant and (2) destination therapy. Advanced heart failure and destination LVADs often carry a poor prognosis. The overall 1-year mortality rate remains as high as 30%. LVAD-specific infections, LVAD-related infections, and non-LVAD-related infections represent important emerging clinical problems in this setting. With an incidence ranging from 30 to 50%, these lead to high rates of hospitalization, morbidity, and mortality. Bacteremias caused by anaerobic pathogens in patients with LVAD are underreported. Herein, we describe the microbiological findings, treatment, and clinical outcome of four patients with LVADs and advanced heart failure with anaerobic bacteremias. Fusobacterium species was the most frequent etiological agent. Most patients had a relatively favorable short-term outcome with survival rates of 100% at 30 days and of 50% at 90 days. However, due to other multiple long-term complications, overall mortality remains at 50% during the first year and increases to 75% beyond the first year. Anaerobic bacteremia sources included the oral cavity from odontogenic infections and aspiration pneumonia. Anaerobic bacteremia constitutes an unfavorable mortality prognostic factor in patients with destination LVADs. We recommend implementing preventive strategies with a comprehensive dental care evaluation in patients with LVADs and advanced heart failure.

Prostate Cancer in Men With Treated Advanced Heart Failure: Should we Keep Screening?

To evaluate the outcomes of men diagnosed with prostate cancer (CaP) following implanted treatments for advanced heart failure. Given the increasingly favorable 10-year life expectancy, MedStar Washington Hospital Center screens heart transplant (HT) candidates for CaP and other malignancies prior to intervention. Men aged 18-90 with available pretransplant Prostate Specific Antigen (PSA) who underwent left ventricular assist device (LVAD) and/or HT at MedStar Washington Hospital Center from 2007 to 2018 were identified. Serum PSA, CaP diagnosis, and treatment were captured and analyzed. Survival was analyzed using Kaplan-Meier curves. Data were available for 34 patients. Median age was 53 [IQR=51-58]. Median follow-up was 77 months (95% CI=40-87 months). Six men had postimplant elevated PSA (5.3; SD=8.5) and 4 were diagnosed with CaP. Median age of CaP diagnosis was 59 [IQR=58.5-62). As of 2018, 31 of the 34 patients were living, and none died from CaP. Five-year survival was 96% in those without CaP and 100% in those with CaP (Figure 2). Our cohort represents the largest known cohort with heart failure treated by LVAD and/or HT and CaP. Our median age of 59 at CaP diagnosis is considerably younger than the national median of 66.1 Of the 4 individuals diagnosed with CaP, 3 had high-grade disease. Given the favorable long-term survival of these patients post-LVAD and/or HT, age-appropriate treatment for CaP should be continued postimplantation.

The Characteristics of Out-Patient Use of Intravenous Milrinone in the United States

Introduction Out-patient inotrope use has limited indications, but the extent of its actual use is not known. We used the SYMPHONY database of about 240 million people (2012-2018) to determine incidence of out-patient milrinone use & the nature of patients (pts) prescribed the medications. Methods Milrinone use was defined as at least 1 use of milrinone in an outpatient setting. To ensure that the drug was not given for testing purposes, no imaging event could be recorded on the same date as the milrinone use. Demographics were calculated, including geographic densities at the Metropolitan Statistical Area level. To estimate the total number of patients receiving these drugs in the US in 2016 & 2017, a population projection was performed to extrapolate from the database population to the total US Population. The projection was normalized based on age, gender & location. Results In 2016, there were 678 pts receiving milrinone as an out-patient in SYMPHONY, leading to a national projection of 1164 ± 96. In 2017, there were 580 pts, with a national projection of 975 ± 88. The SYMPHONY database is similar to census data with slightly less Medicaid and Medicare representation. The milrinone pts were older, more likely to be male, less likely to reside in the West and more likely to have Medicare. The mean age was 54 ± 21 years, with a median of 59 years. Concomitant medication use showed a relatively low prescription of cardiac medications. Loop diuretics were used in 58% of pts, beta adrenergic blockers in 51%, and ACE or ARB in 40%. ICD's were present in 45%, and LVAD's were placed in 8% of pts. More than 20% of pts had some indication of an acute event, with 10% having a morphine or fentanyl prescription, 5% with a prescribed hospital bed at home. Conclusion There is geographic variability in the use of home milrinone, and the patients receiving it are relatively young. While some use of home milrinone appears to be as a bridge to advanced heart failure treatment, much appears to be related to end of life care.

Readmissions after left ventricular assist device implantation: Considerations for nurse practitioners.

Left ventricular assist device (LVAD) therapy is becoming a widespread treatment for advanced heart failure. Implantation of an LVAD introduces complications that contribute to high rates of rehospitalization. This study examines the presenting signs and symptoms in LVAD patients at the time of readmission and explores the prevalence of psychosocial factors that are significantly associated with readmissions in this patient population. This is a retrospective review of 226 patients who had an LVAD implanted at a single transplant center. Data were extracted from individual electronic health record review and analyzed for readmissions within 6 months of discharge from the index hospitalization. Post-LVAD readmission rates are high and occur more frequently in destination therapy (DT) patients. Anxiety and depression are significant predictors of readmission. These factors negatively affect post-LVAD quality of life, particularly in DT patients. By understanding the etiologies and factors related to readmission after an LVAD, nurse practitioners can identify and address these issues before they result in rehospitalization to improve post-LVAD quality of life. With these considerations, ongoing nonemergent discussions of goals of care and quality of life are imperative because more patients will be offered the choice of an LVAD as a potentially life-long treatment.

Does the heart transplant have a future?

Summary Heart failure has remained the leading cause of death globally for the last 15 years—and its prevalence will continue to rise. Fifty years ago, heart failure management was enriched by the possibility of a heart transplant. Despite impressive improvements in medical treatment for heart failure, a heart transplant remains the most effective long-lasting treatment for advanced heart failure in terms of mortality and quality of life. However, donor and recipient characteristics have changed dramatically in recent years, leading to more complex decision-making regarding organ acceptance and to more demanding operations and postoperative management. With improving pathophysiological understanding in the last decades, today’s scientific interest still focuses on basic knowledge. How to retrieve and conserve organs to minimize ischaemic injury; how best to allocate them, considering the likelihood of success (developing a heart-allocation scoring system similar to that for lung allocation); how to match donor/recipient characteristics (ABO blood-group antigen compatibility versus incompatibility); and how to avoid graft failure, rejection and secondary morbidities such as malignomas and cardiac allograft vasculopathy after the heart transplant—all these factors remain fundamental challenges in today’s transplant medicine. The use of ex vivo perfusion (e.g. via the Organ Care System®, TransMedics, Andover, MA, USA) may play an important role in this change. Remarkably, there are huge regional divergences in current transplant practices: Whereas the number of transplants continues to rise in most Eurotransplant countries and other major transplant networks, there are some countries in which transplant numbers are static or even dropping (as in Germany). This difference results in wide variations across different countries as to how advanced heart failure is treated using mechanical circulatory-assist devices.

Left Ventricular Assist Device Outflow Graft Compression: Incidence, Clinical Associations and Potential Etiologies

Left ventricular assist devices (LVADs) have revolutionized the treatment of advanced heart failure, but proliferation of device therapy has unmasked potential complications. Reports have emerged of outflow graft narrowing due to extrinsic compression. The records of patients with LVADs that had been implanted at our institution were reviewed. Those who had postimplantation computed tomography angiographies sufficient to analyze the outflow graft lumen were identified, and the studies were analyzed to characterize the outflow graft lumen. We identified 241 patients; 110 (46%) had suitable computed tomography angiographies. Of those, 15 (14%) had evidence of outflow graft lumen narrowing, all in HeartMate devices and all within the portion covered by the bend relief. Of the 15, 3 underwent invasive examination, all without intraluminal thrombus but, rather, with biodebris between the bend relief and the outflow graft. Patients with HeartWare devices had a wide range of biodebris accumulation surrounding the outflow graft but no cases of lumen narrowing. On multivariable analysis, 1) time from device implant to scan, 2) nonischemic cardiomyopathy and 3) age at implant were significantly associated with higher risk of graft narrowing. Outflow graft narrowing can be seen in a number of patients with HeartMate LVADs within the portion covered by the bend relief. In the limited number of patients who underwent invasive evaluation, the narrowing was found to arise from extrinsic compression rather than intraluminal thrombus. The clinical significance of this requires further investigation.

Left ventricular assist devices in the treatment of advanced heart failure.

The left ventricular assist device (LVAD) is becoming the standard of care in treating patients with advanced heart failure. This article describes available LVADs, their clinical indications, and important caveats when caring for this complex patient population.

Treatment of chemotherapy-associated cardiomyopathy.

The number of cancer survivors is increasing, and cardiovascular events are a significant cause of morbidity and mortality in these patients. Preexisting cardiovascular conditions as well as the development of cancer therapeutics-related cardiac dysfunction (CTRCD), in particular left ventricular dysfunction and heart failure, limit the options for cancer therapies for these patients and contribute to reduced cancer survival. Recent guidelines and position statements from various cardiology and oncology societies provide an outline for the practicing physician for the management of CTRCD. However, this is largely based on data extrapolated from the general heart failure population (including patients without cancers) and is not based on strong evidence. There is now emerging evidence for the prevention and treatment of heart failure related to certain established chemotherapeutic drugs, whereas there is lack of trials for specific cardioprotective strategies to reduce cardiotoxicity of newer targeted cancer therapies. In this article, we discuss the most recent literature for the management of asymptomatic left ventricular dysfunction and heart failure related to chemotherapy, from prevention to the use of goal-directed medical therapies as well as discuss the role for advanced heart failure treatment in this population.