Edo Y. Birati

Left atrial decompression pump for severe heart failure with preserved ejection fraction: theoretical and clinical considerations.

OBJECTIVES The purpose of this study was to provide insight into the potential for left atrium (LA) to aortic mechanical circulatory support as a treatment for patients with heart failure with preserved ejection fraction (HFpEF). BACKGROUND Although HFpEF arises from different etiologies, 1 hallmark of all forms of this syndrome is a small or minimally-dilated left ventricle (LV). Consequently, the use of traditional mechanical circulatory support in end-stage patients has been difficult. In contrast, HFpEF is also characterized by a large LA. METHODS Hemodynamic characteristics of 4 distinct HFpEF phenotypes were characterized from the published data: 1) hypertrophic cardiomyopathies; 2) infiltrative diseases; 3) nonhypertrophic HFpEF; and 4) HFpEF with common cardiovascular comorbidities (e.g., hypertension). Employing a previously-described cardiovascular simulation, the effects of a low-flow, micropump-based LA decompression device were modeled. The effect of sourcing blood from the LV versus the LA was compared. RESULTS For all HFpEF phenotypes, mechanical circulatory support significantly increased cardiac output, provided a mild increase in blood pressure, and markedly reduced pulmonary and LA pressures. LV sourcing of blood reduced LV end-systolic volume into a range likely to induce suction. With LA sourcing, however, LV end-systolic volume increased compared with baseline. Due to pre-existing LA enlargement, LA volumes remained sufficiently elevated, thus minimizing the risk of suction. CONCLUSIONS This theoretical analysis suggests that a strategy involving pumping blood from the LA to the arterial system may provide a viable option for end-stage HFpEF. Special considerations apply to each of the 4 types of HFpEF phenotypes described. Finally, an HFpEF-specific clinical profile scoring system (such as that of INTERMACS [Interagency Registry for Mechanically Assisted Circulatory Support]) would aid in the selection of patients with the appropriate risk-benefit ratio for implantation of an active pump.

The site of origin of torsade de pointes

Objective The electrocardiographic (ECG) characteristics and mode of onset of torsade de pointes (TdP) are well described. Less is known about the site of onset of this arrhythmia. This study was conducted to determine if arrhythmias in the long QT syndrome (LQTS) have a predominant site of origin. Design A retrospective analysis of all episodes of LQTS-related arrhythmias recorded in two university hospitals. Patients Patients with LQTS and no structural heart disease, for whom simultaneous 6–12 leads ECG recording of the onset of TdP was available, were included. Interventions None. Main outcome measures The site of origin of TDP was defined according to the morphology of the initiating ventricular complex based on validated criteria. Multiple-lead recordings of 1025 LQTS-related arrhythmias, including 151 episodes of TdP and 874 QT-related extrasystoles (impending TdP) were available for 50 patients. Results The site of origin of TdP was not homogeneously distributed (p<0.001). Instead, the majority of episodes of TdP (56%) and most QT-related extrasystoles (70%) originated from the outflow tract. There was no correlation between site of origin and the aetiology of LQTS or the QT duration. On a given patient, multiple episodes of TdP tended to originate from the same area and the site of origin of QT-related extrasystoles correlated with the site of origin of TdP. Conclusion The most frequent site of origin of TdP is the outflow tract. Further studies are needed to understand why this relatively small area of the ventricle is a predominant site of origin of diverse ventricular arrhythmias.

Left Ventricular Assist Device Management and Complications

Patients on long-term left ventricular assist device (LVAD) support present unique challenges in the intensive care unit. It is crucial to know the status of end-organ perfusion, which may require invasive hemodynamic monitoring with a systemic arterial and pulmonary artery catheter. Depending on the indication for LVAD support (bridge to decision or cardiac transplantation vs destination therapy), it is important to readdress goals of care with the patient (if possible) and their family after major events have occurred that challenge the survival of the patient.

Right ventricular response to pulsatile load is associated with early right heart failure and mortality after left ventricular assist device

BACKGROUND Right ventricular (RV) adaptation to afterload is crucial for patients undergoing continuous-flow left ventricular assist device (cf-LVAD) implantation. We hypothesized that stratifying patients by RV pulsatile load, using pulmonary arterial compliance (PAC), and RV response to load, using the ratio of central venous to pulmonary capillary wedge pressure (CVP:PCWP), would identify patients at high risk for early right heart failure (RHF) and 6-month mortality after cf-LVAD. METHODS During the period from January 2008 to June 2014, we identified 151 patients at our center with complete hemodynamics prior to cf-LVAD. Pulsatile load was estimated using PAC indexed to body surface area (BSA), according to the formula: indexed PAC (PACi) = [SV / (PAsystolic - PAdiastolic)] / BSA, where SV is stroke volume and PA is pulmonary artery. Patients were divided into 4 hemodynamic groups by PACi and CVP:PCWP. RHF was defined as the need for unplanned RVAD, inotropic support ≥14 days or death due to RHF within 14 days. Risk factors for RHF and 6-month mortality were examined using logistic regression and Cox proportional hazards modeling. RESULTS Sixty-one patients (40.4%) developed RHF and 34 patients (22.5%) died within 6 months. Patients with RHF had lower PACi (0.92 vs 1.17 ml/mm Hg/m2, p = 0.008) and higher CVP:PCWP (0.48 vs 0.37, p = 0.001). Higher PACi was associated with reduced risk of RHF (adjusted odds ratio [adj-OR] 0.61, 95% confidence interval [CI] 0.39 to 0.94, p = 0.025) and low PACi with increased risk of 6-month mortality (adjusted hazard ratio [adj-HR] 3.18, 95% CI 1.40 to 7.25, p = 0.006). Compared to patients with low load (high PACi) and adequate right heart response to load (low CVP:PCWP), patients with low PACi and high CVP:PCWP had an increased risk of RHF (OR 4.74, 95% CI 1.23 to 18.24, p = 0.02) and 6-month mortality (HR 8.68, 95% CI 2.79 to 26.99, p < 0.001). CONCLUSIONS A hemodynamic profile combining RV pulsatile load and response to load identifies patients at high risk for RHF and 6-month mortality after cf-LVAD.

Successful cardiac transplantation outcomes in patients with adult congenital heart disease

Objectives The purpose of our study is (1) to characterise patients with congenital heart disease undergoing heart transplantation by adult cardiac surgeons in a large academic medical centre and (2) to describe successful outcomes associated with our multidisciplinary approach to the evaluation and treatment of adults with congenital heart disease (ACHD) undergoing orthotopic heart transplantation (OHT). Background Heart failure is the leading cause of death in patients with ACHD leading to increasing referrals for OHT. Methods The Penn Congenital Transplant Database comprises a cohort of patients with ACHD who underwent OHT between March 2010 and April 2016. We performed a retrospective cohort study of the 20 consecutive patients. Original cardiac diagnoses include single ventricle palliated with Fontan (n=8), dextro-transposition of the great arteries after atrial switch (n=4), tetralogy of Fallot (n=4), pulmonary atresia (n=1), Ebstein anomaly (n=1), unrepaired ventricular septal defect (n=1) and Noonan syndrome with coarctation of the aorta (n=1). Results Eight patients required pretransplant inotropes and two required pretransplant mechanical support. Nine patients underwent heart–liver transplant and three underwent heart–lung transplant. Three patients required postoperative mechanical circulatory support. Patients were followed for an average of 38 months as of April 2016, with 100% survival at 30 days and 1 year and 94% overall survival (19/20 patients). Conclusions ACHD–OHT patients require highly specialised, complex and multidisciplinary healthcare. The success of our programme is attributed to using team-based, patient-centred care including our multidisciplinary staff and specialists across programmes and departments.

Management of Ventricular Arrhythmias in Patients With Advanced Heart Failure

Advanced heart failure (A-HF) is characterized by progressive symptoms of heart failure despite optimal therapy. In patients with A-HF, ventricular arrhythmias (VAs) are common. Clinical studies evaluating different therapies to prevent VAs had very limited representation of patients with A-HF. Among antiarrhythmic drugs, only amiodarone reduces VAs, although its use may be associated with increased mortality. Catheter ablation with substrate modification is effective to achieve VA suppression in patients with A-HF, including those with left ventricular assist devices. In high-risk cases, temporary mechanical hemodynamic support tailored to the individual patient on the basis of presentation and hemodynamic conditions may be beneficial. Advanced therapies for pump failure or refractory VAs, including heart transplantation and durable mechanical circulatory support, may be required in high-risk patients who are reasonable candidates for these surgical therapies. In this review, the authors discuss important management considerations in patients with VAs and A-HF.

Ventricular assist device thrombosis: A wide spectrum of clinical presentation

Ventricular assist device thrombosis: A wide spectrum of clinical presentation Edo Y. Birati, MD, Ylenia Quiaoit, MSN, ACNP-BC, Joyce Wald, DO, James N. Kirkpatrick, MD, Lee R. Goldberg, MD, MPH, Pavan Atluri, MD, Kenneth B. Margulies, MD, and J. Eduardo Rame, MD, MPhil From the Division of Cardiology; and the Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Post–Heart Transplant Complications

Managing patients after heart transplantation is challenging, since these patients have unique clinical complications (associated with the immunosuppressive therapy and cardiac allograft rejection) together with atypical clinical presentations for infection and systemic inflammatory response syndrome. Survival rates have improved substantially with the use of new immunosuppressive drugs. High vigilance, early diagnosis, and appropriate intervention for allograft-related and non-allograft-related syndromes with significant morbidity and mortality are the keys to long-term survival of patients after transplantation.

Comparison of different anthropometric measurements and inflammatory biomarkers.

Introduction. Different anthropometric variables have been shown to be related to cardiovascular morbidity and mortality. Our aim was to compare the association between different anthropometric measurements and inflammatory status. Methods and results. A cross-sectional study design in which we analyzed the data collected during a five-year period in the Tel Aviv Medical Center Inflammation Survey (TAMCIS). Included in the study were 13,033 apparently healthy individuals at a mean (SD) age of 43. Of these, 8,292 were male and 4,741 female. A significant age-adjusted and multiple-adjusted partial correlation was noted between all anthropometric measurements and all inflammatory biomarkers. There was no significant difference in the correlation coefficients between different biomarkers and anthropometric variables. Conclusion. Most of the common used anthropometric variables are similarly correlated with inflammatory variables. The clinician can choose the variable that he/she finds easiest to use.

Outcomes of rescue cardiopulmonary support for periprocedural acute hemodynamic decompensation in patients undergoing catheter ablation of electrical storm

BACKGROUND In patients with ventricular tachycardia or ventricular fibrillation (VT/VF) electrical storm (ES) undergoing catheter ablation (CA), hypotension due to refractory VT/VF, use of anesthesia, and cardiac stunning due to repeated implantable cardioverter-defibrillator shocks might precipitate acute hemodynamic decompensation (AHD). OBJECTIVE We evaluated the outcomes of emergent cardiopulmonary support with extracorporeal membrane oxygenation (ECMO) to rescue AHD in patients undergoing CA of ES. METHODS Between January 1, 2010 and December 31, 2016, 21 patients with ES (VT in 11 and premature ventricular complex-triggered VF in 10) were referred for CA and had periprocedural AHD requiring emergent ECMO support. RESULTS In 14 patients, AHD occurred a mean of 1.5 ± 1.7 days before the procedure. In the remaining 7 patients, AHD occurred during or shortly after the procedure. ECMO was started successfully in all patients. Ablation was performed in 18 patients (9 with VF and 9 with VT). In patients with VF, premature ventricular complex suppression was achieved in 8 of 9 (89%). In those with VT, noninducibility was achieved in 7 of 9 (78%). After a median follow-up of 10 days, 16 patients died (13 during the index admission). Death was due to refractory VT/VF in 4 patients, heart failure in 11, and noncardiac cause in 1 patient. Seven patients survived beyond 6 months postablation; 5 remained free of VT/VF and 3 ultimately received a destination therapy (heart transplantation in 2 and left ventricular [LV] assist device in 1). CONCLUSION In patients with ES undergoing CA, the outcomes of ECMO support as rescue intervention for AHD are poor. The majority of these patients die of refractory heart failure in the short-term. Strategies to prevent AHD including preemptive use of hemodynamic support may improve survival.