Deepak Acharya

Clinical Characteristics and Outcomes of Intravenous Inotropic Therapy in Advanced Heart Failure

Background—Inotrope use in heart failure treatment was associated with improved symptoms, but worse survival in clinical trials. However, these studies predated use of modern heart failure therapies. This study evaluates contemporary outcomes on long-term inotropes. Methods and Results—We collected baseline and postinotrope data on 197 patients discharged on inotropes between January 2007 and March 2013. Baseline characteristics, hemodynamic and clinical changes on inotropes, and survival were evaluated. Patients initiated on inotropes had refractory heart failure, with median baseline New York Heart Association class IV, cardiac index of 1.7 L/min per m2, pulmonary capillary wedge pressure of 25.6 mm Hg, and left ventricular ejection fraction of 18.7%. Inotropes were used in patients listed for transplant or scheduled for left ventricular assist device (LVAD; 60 patients), in patients being evaluated for LVAD/transplant (20 patients), for stabilization pending cardiac resynchronization therapy/percutaneous coronary intervention (4 patients), in patients who were offered LVAD but chose inotropes (15 patients), and for palliation (98 patients). Milrinone was used in 84.8% and dobutamine in 15.2%. At the end of the study, 68 patients had died, 24 were weaned off inotropes, 23 were transplanted, 32 received LVADs, and 50 remained on inotropes. Patients who received inotropes for palliation or those who preferred inotropes over LVAD had median survival of 9.0 months (interquartile range, 3.1–37.1 months), actuarial 1-year survival of 47.6%, and 2-year survival of 38.4%. Of 60 patients who were placed on inotropes as a bridge to transplant/LVAD, 55 were successfully maintained on inotropes until transplant/LVAD. Conclusions—Survival on inotropes for patients who are not candidates for transplant/LVAD is modestly better than previously reported, but remains poor. Inotropes are effective as a bridge to transplant/LVAD.

Arrhythmias in Fabry Cardiomyopathy

Prior studies suggest that the incidence of ventricular arrhythmias is high in patients with Fabry cardiomyopathy. This study evaluated the incidence of significant arrhythmias in a series of patients with Fabry cardiomyopathy.

Octreotide in the management of recurrent gastrointestinal bleed in patients supported by continuous flow left ventricular assist devices.

Gastrointestinal (GI) bleeding is the most common cause of readmission in patients supported by continuous flow left ventricular assist devices (CF-LVAD). We describe our experience in the off-label use of octreotide in the management of recurrent GI bleed in this population. Of 116 patients implanted with a CF-LVAD at our institution, seven had recurrent GI bleeding unresponsive to conventional management and were started in chronic octreotide injections. Hospitalizations due to GI bleeding, number of packed red blood cells transfused, and number of endoscopic procedures were compared 3 months before and after octreotide treatment. In the overall cohort, there were no differences in these three endpoints. When one patient with differing characteristics was excluded from the analysis there was a trend (p = 0.06) to a reduction of hospitalizations due to GI bleeding, number of blood transfusions, and number of endoscopic procedures. Octreotide exhibit a favorable trend in the frequency of admissions, blood transfusions, and endoscopic procedures in most patients with recurrent GI bleed. Further prospective studies are needed to clarify its benefits in this population.

Outcomes of Patients With Peripartum Cardiomyopathy Who Received Mechanical Circulatory Support

Background— We describe the characteristics and outcomes of peripartum cardiomyopathy (PPCMP) patients who received durable mechanical circulatory support and compared it with other etiologies of advanced heart failure. Methods and Results— We analyzed 1258 women who were registered in Interagency Registry for Mechanically Assisted Circulatory Support between June 2006 and March 2012. Baseline characteristics, implant strategies, hemodynamics, echocardiographic data, and outcomes were compared. Ninety-nine women had PPCMP and 1159 had non-PPCMP as primary diagnosis. PPCMP women were younger ( P <0.001), more likely to be blacks, and had less comorbidities than non-PPCMP patients. PPCMP women had better survival than non-PPCMP women ( P =0.01) with a 2-year survival of 83%. Multivariable risk factor adjustment analysis showed that the improved survival was likely because of younger age and fewer comorbidities. At 36 months, a proportion of 48% PPCMP received heart transplantation. Recovery occurred at a frequency of 6% and 2% in the PPCMP and non-PPCMP groups ( P =0.1). Adverse event rates were similar in PPCMP and non-PPCMP patients except for higher cardiac arrhythmias and respiratory failure in the non-PPCMP in the first 3 months post implant. Conclusions— PPCMP women who receive durable mechanical circulatory support have a better survival than women with non-PPCPM. The improved survival observed in PPCMP is likely related to their fewer comorbidities and younger age. Myocardial recovery was uncommon and less than half of women with end-stage PPCPM received heart transplantation after 3 years of mechanical support.Background— We describe the characteristics and outcomes of peripartum cardiomyopathy (PPCMP) patients who received durable mechanical circulatory support and compared it with other etiologies of advanced heart failure. Methods and Results— We analyzed 1258 women who were registered in Interagency Registry for Mechanically Assisted Circulatory Support between June 2006 and March 2012. Baseline characteristics, implant strategies, hemodynamics, echocardiographic data, and outcomes were compared. Ninety-nine women had PPCMP and 1159 had non-PPCMP as primary diagnosis. PPCMP women were younger (P<0.001), more likely to be blacks, and had less comorbidities than non-PPCMP patients. PPCMP women had better survival than non-PPCMP women (P=0.01) with a 2-year survival of 83%. Multivariable risk factor adjustment analysis showed that the improved survival was likely because of younger age and fewer comorbidities. At 36 months, a proportion of 48% PPCMP received heart transplantation. Recovery occurred at a frequency of 6% and 2% in the PPCMP and non-PPCMP groups (P=0.1). Adverse event rates were similar in PPCMP and non-PPCMP patients except for higher cardiac arrhythmias and respiratory failure in the non-PPCMP in the first 3 months post implant. Conclusions— PPCMP women who receive durable mechanical circulatory support have a better survival than women with non-PPCPM. The improved survival observed in PPCMP is likely related to their fewer comorbidities and younger age. Myocardial recovery was uncommon and less than half of women with end-stage PPCPM received heart transplantation after 3 years of mechanical support.

Use of Gated Cardiac Computed Tomography Angiography in the Assessment of Left Ventricular Assist Device Dysfunction

The purpose of this study is to describe the utility and limitations of gated contrast-enhanced cardiac computed tomography angiography in assessing left ventricular assist device function. Computed tomography angiography (CTA) was used in 14 patients with left ventricular assist devices (LVADs) who had persistent heart failure symptoms, hemodynamic instability, or potential problems with LVAD flows. Retrospectively gated contrast-enhanced CTA was performed on 64-detector scanner, and the CTA images were postprocessed in multiple curved projections on TeraRecon workstation. This study describes the use of CTA to identify LVAD-related issues that altered clinical management and explores the role of CTA and other techniques in evaluating LVAD function. Six of 14 LVAD patients who demonstrated no abnormality on CTA remained stable with medical management. In the remaining eight patients, CTA was abnormal, including abnormalities specifically related to the LVAD cannula. As a result of findings detected by CTA, six patients underwent surgical intervention, including device exchange and heart transplant. Computed tomography angiography is a noninvasive method that enhances diagnostic evaluation of patients with suspected LVAD dysfunction and can lead to changes in patient management.

Outcomes of Patients With Peripartum Cardiomyopathy Who Received Mechanical Circulatory Support Data From the Interagency Registry for Mechanically Assisted Circulatory Support

Background— We describe the characteristics and outcomes of peripartum cardiomyopathy (PPCMP) patients who received durable mechanical circulatory support and compared it with other etiologies of advanced heart failure. Methods and Results— We analyzed 1258 women who were registered in Interagency Registry for Mechanically Assisted Circulatory Support between June 2006 and March 2012. Baseline characteristics, implant strategies, hemodynamics, echocardiographic data, and outcomes were compared. Ninety-nine women had PPCMP and 1159 had non-PPCMP as primary diagnosis. PPCMP women were younger ( P <0.001), more likely to be blacks, and had less comorbidities than non-PPCMP patients. PPCMP women had better survival than non-PPCMP women ( P =0.01) with a 2-year survival of 83%. Multivariable risk factor adjustment analysis showed that the improved survival was likely because of younger age and fewer comorbidities. At 36 months, a proportion of 48% PPCMP received heart transplantation. Recovery occurred at a frequency of 6% and 2% in the PPCMP and non-PPCMP groups ( P =0.1). Adverse event rates were similar in PPCMP and non-PPCMP patients except for higher cardiac arrhythmias and respiratory failure in the non-PPCMP in the first 3 months post implant. Conclusions— PPCMP women who receive durable mechanical circulatory support have a better survival than women with non-PPCPM. The improved survival observed in PPCMP is likely related to their fewer comorbidities and younger age. Myocardial recovery was uncommon and less than half of women with end-stage PPCPM received heart transplantation after 3 years of mechanical support.Background— We describe the characteristics and outcomes of peripartum cardiomyopathy (PPCMP) patients who received durable mechanical circulatory support and compared it with other etiologies of advanced heart failure. Methods and Results— We analyzed 1258 women who were registered in Interagency Registry for Mechanically Assisted Circulatory Support between June 2006 and March 2012. Baseline characteristics, implant strategies, hemodynamics, echocardiographic data, and outcomes were compared. Ninety-nine women had PPCMP and 1159 had non-PPCMP as primary diagnosis. PPCMP women were younger (P<0.001), more likely to be blacks, and had less comorbidities than non-PPCMP patients. PPCMP women had better survival than non-PPCMP women (P=0.01) with a 2-year survival of 83%. Multivariable risk factor adjustment analysis showed that the improved survival was likely because of younger age and fewer comorbidities. At 36 months, a proportion of 48% PPCMP received heart transplantation. Recovery occurred at a frequency of 6% and 2% in the PPCMP and non-PPCMP groups (P=0.1). Adverse event rates were similar in PPCMP and non-PPCMP patients except for higher cardiac arrhythmias and respiratory failure in the non-PPCMP in the first 3 months post implant. Conclusions— PPCMP women who receive durable mechanical circulatory support have a better survival than women with non-PPCPM. The improved survival observed in PPCMP is likely related to their fewer comorbidities and younger age. Myocardial recovery was uncommon and less than half of women with end-stage PPCPM received heart transplantation after 3 years of mechanical support.

Have risk factors for mortality after heart transplantation changed over time? Insights from 19 years of Cardiac Transplant Research Database study

BACKGROUND The Cardiac Transplant Research Database (CTRD) collected data from 26 U.S. institutions from January 1, 1990 to December 31, 2008 providing the opportunity for construction of a comprehensive multivariable model of risk for death after transplantation. We analyzed risk factors for death over 19 years of experience to determine how risk profiles have changed over time and how they interact with age. METHODS A multivariable parametric hazard model for death was created for 7,015 patients entered into the CTRD. Variables collected over 19 years of experience were examined as potential risk factors and tested for interaction with date of transplantation to determine if their relative risk (RR) changed over time. RESULTS The hazard for death post-transplant occurred in 2 phases: an early phase of acute risk lasting <1 year, and a late phase of relatively low, gradually increasing risk (<0.1 event/year). In the early phase, predictive models showed that ventricular assist device (VAD) at the time of transplant did not increase the RR of death for recipient transplant at 30 years of age, but the RR of death was increased by 60% (p = 0.04) at 60 years of age. Of the late-phase variables found to be risk factors, the RR of age, date of transplant and pulmonary vascular resistance changed with respect to transplant year. The overall risk of death dropped importantly over the study period, but the RR of all other variables remained unchanged. RR was 2.6 (p < 0.0001) for 25-year-old African-American (AA) versus non-AA recipients and 1.6 for 60-year-old AA recipients (p = 0.02). CONCLUSION Over 19 years, the baseline risk of death has decreased, but the specific risk factors and the magnitudes of their RR have remained unchanged. Therefore, despite advances in clinical management and improvement in overall survival, the risk profile for death after cardiac transplantation is similar to that in 1990.

Infections, Arrhythmias, and Hospitalizations on Home Intravenous Inotropic Therapy

Inotropes improve symptoms in advanced heart failure (HF) but were associated with higher mortality in clinical trials. Recurrent hospitalizations, arrhythmias, and infections contribute to morbidity and mortality, but the risks of these complications with modern HF therapies are not well known. We collected arrhythmia, infection, and hospitalization data on 197 patients discharged from our institution from January 2007 to March 2013 on intravenous inotropes. Patients were followed until they died, received a transplant or left ventricular assist device, were weaned off inotropes, or remained on inotropes at the end of the study. All patients had stage D HF. At baseline, 30% had a history of ventricular tachycardia, 7.1% had a history of cardiac arrest, and 39% had a history of atrial fibrillation. During follow-up, 33 patients (17%) had one or more implantable cardioverter-defibrillator shocks. Of patients who had shocks, 27 patients (82%) had appropriate shocks for ventricular tachycardia/ventricular fibrillation, 3 patients (9%) had inappropriate shocks, and 3 patients (9%) had both appropriate and inappropriate shocks. The risk of implantable cardioverter-defibrillator shock was not related to dose of inotrope (p = 0.605). Fifty-seven patients (29%) had one or more infections during follow-up. Bacteremia was the most common type of infection. Implanted electrophysiology devices did not confer an increased risk of infection. One hundred twelve patients (57%) had one or more hospitalizations during follow-up. Common causes of hospitalizations were worsening HF symptoms (41%), infections (20%), and arrhythmias (12%). In conclusion, arrhythmias, infections, and rehospitalizations are important complications of inotropic therapy.

Duration of Heart Failure Is an Important Predictor of Outcomes After Mechanical Circulatory Support

Background—Heart failure (HF) progression results in worsening functional capacity and end-organ compromise. HF may occur acutely or be associated with a chronic presentation. We hypothesized that the duration of HF affects outcomes after mechanical circulatory support. Methods and Results—A total of 10 730 patients registered in Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) who received primary implant of a mechanical circulatory support device were stratified according to the duration of HF symptoms: acute HF (AHF; ⩽1 month), sub-AHF (1–12 months), and chronic HF (Cr-HF; ≥ 12 months). AHF patients were younger with a higher proportion of women and white and with a lower prevalence of peripheral vascular disease and history of prior cardiac surgeries. Sixty percent of AHF patients were INTERMACS profile 1 at the time of implantation versus 24% and 13.2% in the sub-AHF and Cr-HF groups, respectively (P=0.0001). Patients with AHF had the highest utilization of biventricular support (14.4%). The estimated survival at 4 years was 58%, 51%, and 45% for the AHF, sub-AHF, and Cr-HF patients (P=0.006). The proportion of patients with AHF who received heart transplantation at 1 year was 29% compared with 22.6% in the patients with Cr-HF. After adjustment for known risk factors of adverse outcome, patients with AHF have a better late phase prognosis compared with patients with Cr-HF (hazard ratio, 0.34; P=0.0003). Conclusions—The duration of HF before durable mechanical circulatory support implant is an important variable influencing outcome. Patients with AHF had improved survival at 4 years and higher rates of transplantation at 1 year despite higher acuity of presentation.

Assessment and management of right ventricular failure in left ventricular assist device patients.

Mechanical circulatory support devices, including ventricular assist devices (VADs) and the total artificial heart, have evolved to become accepted therapeutic options for patients with severe congestive heart failure. Continuous-flow left VADs are the most prevalent option for mechanical circulatory assistance and reliably provide years of support. However, problems related to acute and chronic right heart failure in patients with left VADs continue to cause important mortality and morbidity. This review discusses the assessment and management of right ventricular failure in left VAD patients. The goal is to summarize current knowledge and suggest new approaches to managing this problem.