David M. Venesy

Clinical Characteristics of Tako-Tsubo Cardiomyopathy

Tako-tsubo cardiomyopathy (TTC) is increasingly diagnosed in the United States, especially in the Caucasian population. To evaluate the clinical features and outcome of patients with TTC, we evaluated 34 patients (32 women and 2 men) 22 to 88 years of age (mean 66 +/- 14) who fulfilled the following criteria: (1) akinesia or dyskinesia of the apical and/or midventricular segments of the left ventricle with regional wall motion abnormalities that extended beyond the distribution of a single epicardial vessel and (2) absence of obstructive coronary artery disease. Twenty-five patients (74%) presented with chest pain, 20 patients (59%) presented with dyspnea, and 8 patients (24%) presented with cardiogenic shock. Twenty-two patients (65%) had ST-segment elevation and 14 patients (41%) had T-wave inversion on presentation. Twenty-five patients (74%) reported a preceding stressful event. Cardiac biomarkers were often mildly increased, with a mean troponin I (peak) of 13.9 +/- 24. Mean +/- SD left ventricular ejection fractions were 28 +/- 10% at time of presentation and 51 +/- 14 at time of follow-up (p <0.0001). Two patients (6%) died during the hospital stay. Average duration of hospital stay was 6.6 +/- 6.2 days. In conclusion, TTC is common in postmenopausal women with preceding physical or emotional stress. It predominantly involves the apical portion of the left ventricle and patients with this condition have a favorable outcome with appropriate medical management. The precise cause remains unclear.

A Multicenter Randomized Controlled Evaluation of Automated Home Monitoring and Telephonic Disease Management in Patients Recently Hospitalized for Congestive Heart Failure: The SPAN-CHF II Trial

BACKGROUND We performed a prospective, randomized investigation assessing the incremental effect of automated health monitoring (AHM) technology over and above that of a previously described nurse directed heart failure (HF) disease management program. The AHM system measured and transmitted body weight, blood pressure, and heart rate data as well as subjective patient self-assessments via a standard telephone line to a central server. METHODS AND RESULTS A total of 188 consented and eligible patients were randomized between intervention and control groups in 1:1 ratio. Subjects randomized to the control arm received the Specialized Primary and Networked Care in Heart Failure (SPAN-CHF) heart failure disease management program. Subjects randomized to the intervention arm received the SPAN-CHF disease management program in conjunction with the AHM system. The primary end point was prespecified as the relative event rate of HF hospitalization between intervention and control groups at 90 days. The relative event rate of HF hospitalization for the intervention group compared with controls was 0.50 (95%CI [0.25-0.99], P = .05). CONCLUSIONS Short-term reductions in the heart failure hospitalization rate were associated with the use of automated home monitoring equipment. Long-term benefits in this model remain to be studied.

Health-Related Quality of Life in a Multicenter Randomized Controlled Comparison of Telephonic Disease Management and Automated Home Monitoring in Patients Recently Hospitalized With Heart Failure: SPAN-CHF II Trial

BACKGROUND Although disease management programs have been shown to provide a number of clinical benefits to patients with heart failure (HF), the incremental impact of an automated home monitoring (AHM) system on health-related quality of life (HRQL) is unknown. METHODS AND RESULTS We performed a prospective randomized investigation, examining the additive value of AHM to a previously described nurse-directed HF disease management program (SPAN-CHF), with attention to HRQL, in patients with a recent history of decompensated HF. A total of 188 patients were randomized to receive the SPAN-CHF intervention for 90 days, either with (AHM group) or without (NAHM, standard-care group) AHM, with a 1:1 randomization ratio after HF-related hospitalization. HRQL, measured by the Minnesota Living With Heart Failure Questionnaire (MLHFQ) (Physical, Emotional, and Total scores on MLHFQ) was assessed at 3 time points: baseline, 45 days, and 90 days. Although both treatments (AHM and NAHM) improved HRQL at 45 and 90 days compared with baseline with respect to Physical, Emotional, and Total domain scales, no significant difference emerged between AHM and NAHM groups. CONCLUSIONS AHM and NAHM treatments demonstrated improved HRQL scores at 45 and 90 days after baseline assessment. When comparing 2 state-of the-art disease management programs regarding HRQL outcomes, our results did not support the added value of AHM.

Identifying patients for safe early hospital discharge following st elevation myocardial infarction.

To examine whether the CADILLAC risk score is an effective method of patient stratification for early discharge following ST elevation myocardial infarction (STEMI).

Transaortic, video-assisted removal of a mobile left ventricular apical thrombus in a patient with aortic stenosis and severe left ventricular dysfunction

From the Department of Thoracic and Cardiovascular Surgery, Lahey Hospital and Medical, Center, Burlington, Mass; the Department of Anesthesiology, Lahey Hospital andMedical, Center, Burlington, Mass; and the Department of Cardiology, Lahey Hospital and Medical Center, Burlington, Mass. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Aug 14, 2015; revisions received Sept 15, 2015; accepted for publication Sept 22, 2015; available ahead of print Oct 26, 2015. Address for reprints: Christina Williamson, MD, Department of Thoracic and Cardiovascular Surgery, Lahey Hospital and Medical Center, 41 Mall Rd, Burlington, MA 01805 (E-mail: christina.williamson@lahey.org). J Thorac Cardiovasc Surg 2016;151:e1-3 0022-5223/

Ibrutinib-Associated Atrial Fibrillation

36.00 Copyright 2016 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2015.09.091 Transaortic view of left ventricular apical thrombus.

Beta Blocker Utilization in Systolic Heart Failure: A Multispecialty Group Practice Experience

Ibrutinib, a novel and potent Bruton tyrosine kinase inhibitor, is an effective and well-tolerated treatment for a variety of B-cell lymphomas. However, its use is associated with an increased incidence of atrial fibrillation (AF), ranging from 4% to 16%. We reviewed the original clinical trials that led to the approval of ibrutinib, as well as several other prospective and retrospective studies, to better appreciate the incidence of ibrutinib-associated AF. Based on 16 studies included in our analysis, the incidence of ibrutinib-associated AF was 5.77 per 100 person-years, which is much higher than rates previously reported with ibrutinib and compared with the general adult population. New onset AF in cancer patients is associated with a significantly higher risk of heart failure and thromboembolism, even after adjusting for known risk factors. In addition, ibrutinib poses unique challenges due to its interactions with many medications that are commonly used to manage AF. Ibrutinib also inhibits platelet activation and decisions regarding anticoagulation have to be carefully weighed against this increased risk of bleeding. Ibrutinibs interaction with calcium channel blockers, digoxin, amiodarone, and direct oral anticoagulants can result in either ibrutinib or other drug-related toxicity and careful selection and dose adjustment may be needed. Ibrutinib-associated AF can be a therapy-limiting side effect and physicians should be familiar with the special management considerations imposed by this agent. We review the potential mechanisms and incidence of ibrutinib-associated AF and propose an algorithm for its management.

Single-center experience with the TandemHeart percutaneous ventricular assist device to support patients undergoing high-risk percutaneous coronary intervention.

Background: Over the past decade several large randomized clinical trials have demonstrated the efficacy of beta blockers in the management of heart failure associated with systolic dysfunction. Although this evidence has been incorporated into several clinical practice guidelines, the actual utilization of beta blockers in everyday clinical practice has not been well studied since the most recent guidelines were published. Methods: During a three month period (January 15–April 15, 2002), consecutive echo reports at the Lahey Clinic Medical Center, a multispecialty group practice in Burlington,Massachusetts, were reviewed for (1) EF 40%and (2) primary care provided at the Lahey Clinic in Burlington . Medical records were analyzed for beta blocker utilization during the 90 day period following the index echo. Results: A total of 119 patients were identified. Eighteen patients were excluded because the medical record was unavailable or the patient died during the 90 day follow-up period, leaving 101 patients as the study population. This population was predominantly male (66%) with a mean age of 71 years and CAD as the etiology of systolic dysfunction in 62%. During the study period, follow-up outpatient visits with the following physicians were documented: primary care physician only: 18%; cardiologist only: 28%; both: 48%; neither: 7%. Nineteen of the 101 patients were not receiving beta blockers, with documented reasons in nine patients: 3 depression, 2 hypotension, 1 bradycardia, 1 “intolerant”, 2 patient refusal. Excluding the nine patients with documented reasons for not taking beta blockers, a total of 92 patients were deemed eligible for beta blocker therapy. Suitability of the VeriCor System, a Non-Invasive Device That Estimates Left Ventricular End-Diastolic Pressure for Screening Patients at High Risk of Developing Heart Failure G.V.R.K. Sharma, Patricia A. Woods, Louise Connolly, Peter Sachetti, Kevin M. McIntyre2—Department of Medicine, VA Healthcare System and Harvard Medical School, Boston, MA; Boston, MA, Boston, MA