Arvind Bhimaraj

Increased right-to-left ventricle diameter ratio is a strong predictor of right ventricular failure after left ventricular assist device.

BACKGROUNDnPredictors of right ventricular failure (RVF) in patients with left ventricular assist devices (LVADs) have not been fully elucidated and are comprised mostly of clinical variables. We evaluated echocardiographic parameters associated with adverse outcomes in this population.nnnMETHODSnTransthoracic echocardiograms (TTEs) before continuous-flow LVAD implantation were analyzed in 109 patients. Twenty-six 2-dimensional and Doppler parameters were assessed for their association with the primary outcome of 30-day RVF, defined as a requirement of an RV assist device or ≥ 14 consecutive days of inotropic support, and the secondary composite outcome of 30-day death or RVF. Multivariate analysis adjusted for known clinical risk prediction models was performed.nnnRESULTSnOverall, 25 (22.9%) and 27 (24.8%) patients reached the primary and secondary end-points, respectively. An increased RV/LV diameter ratio was the only TTE variable independently associated with both the primary (odds ratio [OR] = 5.40; 95% confidence interval [CI] 2.40 to 12.40; p = 0.012) and secondary (OR = 2.70; 95% CI 1.06 to 6.22; p = 0.03) outcomes after multivariate analysis. Scatterplot analysis with regression determined the optimal cut-off value for RV/LV diameter to be 0.75. Based on receiver operating characteristic curves, an increased RV/LV diameter ratio provided an additional predictive value to clinical risk scores.nnnCONCLUSIONSnA TTE-measured RV/LV diameter ratio of ≥0.75 is independently associated with a higher risk for RVF in patients with continuous-flow LVAD. When used alone, this simple, easily derived, practical echocardiographic measurement has a predictive value equivalent to known clinical risk scores, whereas their combination provides stronger risk prediction for adverse outcomes.

Percutaneous Placement of an Intra-Aortic Balloon Pump in the Left Axillary/Subclavian Position Provides Safe, Ambulatory Long-Term Support as Bridge to Heart Transplantation

OBJECTIVESnThis study evaluated the feasibility, tolerability, and efficacy of a strategy for percutaneous intra-aortic balloon pump (IABP) placement through the left axillary-subclavian artery to provide mechanical circulatory support in patients with end-stage heart failure as a bridge to heart transplantation.nnnBACKGROUNDnThe transfemoral approach to IABP placement is associated with major disadvantages, including the risk for infection and limitation of patient mobility in those requiring extended support.nnnMETHODSnWe developed a percutaneous technique for placing IABPs in the left axillary artery that permits upright sitting and ambulation. We performed a retrospective review of data from patients who had undergone left axillary IABP implantation between 2007 and 2012.nnnRESULTSnFifty patients who received a left axillary IABP as a bridge to transplantation were identified, of whom 42 (84%) underwent heart or heart-multiorgan transplantation. Cumulative survival on IABP support was 92%, and post-transplant 90-day survival was 90%. Median duration of support was 18 days. Four of 50 patients (8%) died while on IABP support, and 3 (6%) received greater mechanical circulatory support. Four patients (8%) had clinically significant thromboembolic or bleeding events without long-term sequelae. The most common minor adverse event was IABP malposition, in 22 patients (44%). Prolonged IABP support in the heart-transplantation cohort was associated with significant improvements in mean pulmonary artery pressure and in creatinine and total bilirubin concentrations.nnnCONCLUSIONSnPercutaneous insertion of an IABP through the left axillary artery is a feasible and relatively well-tolerated strategy to bridge patients with end-stage heart failure to heart transplantation. This form of mechanical-device treatment permits upright sitting and ambulation in those requiring extended support.

Ventricular assist devices: a review of psychosocial risk factors and their impact on outcomes.

BACKGROUNDnPsychosocial contraindications for ventricular assist devices (VADs) remain particularly nebulous and are driven by institution-specific practices. Our multi-institutional, multidisciplinary workgroup conducted a review with the goal of addressing the following research question: How are preoperative psychosocial domains predictive of or associated with postoperative VAD-related outcomes? Answers to this question could contribute to the development of treatment-specific (contra) indications for patients under consideration for mechanical devices.nnnMETHODS AND RESULTSnWe identified 5 studies that examined psychosocial factors and their relationship to postoperative VAD-related outcomes. Our results suggest that 3 psychosocial variables are possibly associated with VAD-related outcomes: depression, functional status, and self-care. Of the few studies that exist, the generalizability of findings is constrained by a lack of methodologic rigor, inconsistent terminology, and a lack of conceptual clarity.nnnCONCLUSIONSnThis review should serve as a call for research. Efforts to minimize psychosocial risk before device placement can only be successful insofar as VAD programs can clearly identify who is at risk for suboptimal outcomes.

Physiological impact of continuous flow on end-organ function: clinical implications in the current era of left ventricular assist devices.

The clinical era of continuous-flow left ventricular assist devices has debunked many myths about the dire need of a pulse for human existence. While this therapy has been documented to provide a clear survival benefit in end-stage heart failure patients, we are now faced with certain morbidity challenges that as of yet have no easy mechanistic physiological explanation. The effect of physiological changes on end-organ function in patients supported by continuous-flow ventricular assist devices may offer insight into some of these morbidities. We therefore present a review of current evidence documenting the impact of continuous flow on end-organ function.

High proportion of patients with end-stage heart failure regardless of aetiology demonstrates anti-cardiac antibody deposition in failing myocardium: humoral activation, a potential contributor of disease progression

AIMSnVarious reports have raised the possibility of humoral immune responses as contributors for the progression of heart failure. Previous studies, however, have focused on the analysis of serum and documented circulating antibodies against a variety of cardiac proteins. However, there is little evidence on whether anti-cardiac antibodies are deposited in end-stage failing myocardium. Our objective was to determine whether or not there was evidence of deposition of anti-cardiac antibodies and/or activated complement components in end-stage failing human myocardium.nnnMETHODS AND RESULTSnMyocardial samples were obtained from 100 end-stage heart failure patients and 40 donor control biopsies. Sections were cut and stained using standard fluorescent immunohistochemistry techniques with anti-human immunoglobulin G (IgG), IgG3, and C3c. Gel electrophoresis and protein identification by mass spectrometry were used to confirm the presence of IgG and its antigen. Immunoglobulin G was localized to the sarcolemma in 71% of patients, 48% of those being positive for the subtype IgG3. The proportion of patients with ischaemic heart disease that was positive for IgG was 65% and among those with non-ischaemic aetiologies was 76%. In a subgroup analysis, the presence of IgG and its subunits were confirmed by mass spectrometry and adenosine triphosphate synthase β subunit identified as an antigen. Complement was activated in 31% of all patients. The presence of IgG, IgG3, and C3c was directly correlated with the length of disease (r = 0.451, P = 0.006).nnnCONCLUSIONnEvidence of anti-cardiac antibodies and complement activation was found in a large number of patients with end-stage cardiomyopathy regardless of the aetiology. Adenosine triphosphate synthase appears to be a new prominent antigenic stimulus; but more interestingly, the simultaneous co-existence of activated complement components suggests that this humoral mechanism may participate in disease progression.

MDCT assessment of mechanical circulatory support device complications

THE RISING NUMBER OF PATIENTS WITH ADVANCED HEART FAILURE WHO RECEIVE DURABLE MECHANICAL CIRCULATORY SUPPORT (MCS) DEVICES requires improved recognition of device complications [(1)][1]. Imaging is invariably needed because the clinical presentation is nonspecific. In our institution, we perform

Robotically Guided Left Ventricular Biopsy to Diagnose Cardiac Sarcoidosis: A Multidisciplinary Innovation Leading to First-in-Human Case

Sarcoidosis may affect the heart in ≤25% of patients with known involvement of other organs.1 Because of the patchy and unpredictable nature of the infiltrate location, traditional endomyocardial biopsy of the right ventricular septum lacks sensitivity, and imaging and electroanatomic mapping (EAM) guidance can increase sensitivity.2,3 Involved areas may be difficult to reach with standard bioptome. We present a case using robotic assistance to overcome such limitation.nnA 44-year-old healthy white female presented with syncope and dyspnea on exertion. Her electrocardiogram showed complete atrioventricular block with ventricular escape rhythm. Echocardiogram was normal, but cardiac magnetic resonance showed hypokinesis and hyperenhancement post-gadolinium in the basal anterior septum, right ventricle free wall, and mid anterolateral left ventricular (LV) wall suspicious for infiltrative cardiomyopathy. An electrophysiological study was performed showing inducible monomorphic ventricular tachycardia (VT) leading to a defibrillator placement. Standard biopsy, angiogram, and contrast chest computed tomography were noncontributory. She represented within 2 weeks with multiple defibrillator shocks because of multiple VT episodes, failed amiodarone, and hence an ablation was planned. Empirical …

Revisiting Surrogate Consent for Ventricular Assist Device Placement

hen patients lack decision-making capacity, their Wsurrogate decision makers (designated by an advance directive or by legally established hierarchies) make decisions on behalf of patients in keeping with patient values, goals, and preferences, an ethical concept known as “substituted judgment” [1]. Existing ethical recommendations advocate using only the patient and discourage using surrogate decision makers when initiating ventricular assist device (VAD) placement as destination therapy (DT) [2–4]. For example, in a 2006 Annals of Thoracic Surgery article, Dudzinski [3] wrote that, “patients who lack capacity to voluntarily consent should not be offered DT because they are unable to weigh benefits and burdens.” The justifications provided in these recommendations are that VAD-DT placement is a noncurative, highly preference-sensitive decision involving tradeoffs and lifestyle changes that, ideally, only patients and clinicians should weigh (ie, “first person” consent) [3, 4]. The following case highlights the limitations of existing ethical recommendations and the complexities involved in using surrogate consent for device placement. We offer ethically justified strategies for responding to these challenges. Mr K, a 50-year-old patient with ischemic cardiomyopathy and end-stage heart failure (New York Heart Association class IIIB), was admitted to our hospital in cardiogenic shock and renal failure. He had not been previously admitted to our hospital or been seen in our outpatient clinics. Upon admission, he was intubated, on high-dose pressor support, and continuous hemodialysis. He underwent placement of an intraaortic balloon pump, resulting in minimal improvement in his clinical status. The patient lacked decision-making capacity. Using a surrogate consent process, the heart failure team discussed with Mr K’s wife percutaneous VAD support with a TandemHeart (Cardiac Assist Inc, Pittsburgh, PA), with the goal of long-term VAD support with a HeartMate II LVAD (Thoratec, Pleasanton, CA) as bridge-to-decision. According to her, VAD support had never been discussed with her or her husband, and she was uncertain about his wishes. She remarked that her husband said he “never wanted to live on life support.” However, she acknowledged that these statements were

Right ventricle chest compressions: do we need a new paradigm for LVAD patients needing resuscitation? A case report.

The use of chest compressions in patients with left ventricular assist devices (LVAD) have been viewed to cause a potential damage to the outflow graft and hence have been a topic of controversy. We report a case of a LVAD patient who needed chest compressions during resuscitation for severe right ventricular failure. With the presence of trans-esophageal echocardiogram we noticed that the chest compressions did not need to be full ACLS compressions but modified to gentle right ventricular (RV) compressions in order to move blood into a normally functioning LVAD. We report this as a call for the LVAD medical providers to rethink concepts of standard resuscitation.

Melding a High-Risk Patient for Continuous Flow Left Ventricular Assist Device into a Low-Risk Patient

The model for end-stage liver disease (MELD) has been used as a predictor of mortality after left ventricular assist device (LVAD) placement. However, improvement or worsening of MELD and how those changes affect outcomes is unknown. We performed a retrospective analysis of 244 patients implanted with a continuous flow (CF) LVAD. Patients were dichotomized at admission into low- or high-risk categories using a cutoff of MELD ≥ 19, and they were reclassified at day of implant forming four groups: Group LL (low to low, remained low risk), LH (low to high, worsened to high risk), HH (high to high, remained high risk), and HL (high to low, improved to low risk). Patients who improved to a low risk (group HL) had the same 1 year survival as those that remained low risk (group LL; 80% vs. 77%; p = 0.6). However, patients who were initially classified as low risk and worsened to a high risk (group LH) had a survival that was worse than those that were consistently high risk (group HH; 55% vs. 10%; p = 0.01). Model for end-stage liver disease reclassification after adjusting for commonly attributed risk factors remained an independent predictor for mortality, including patients classified as Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) 1 and 2. In conclusion, our MELD score reclassification is an independent and powerful predictor of mortality in patients undergoing LVAD implantation.