Indranee Rajapreyar

Systemic Candidiasis and Cytomegalovirus Infection in the Setting of Artificial Cardiac Device Deployment

Heart failure is a serious cause of morbidity and mortality worldwide. The advent of implantable cardiac assist devices has generated a new arsenal for treating severe heart failure. However, the potential ramifications of ventricular assist device (VAD) usage are not fully understood. Immune modulation resulting from VAD implantation is an area of growing research. Although we do not fully understand the mechanisms contributing to host immune alteration, changes in cytokine concentrations, deceased lymphocyte activity, and the local effects of device materials have been shown to down regulate immune function. Infection is a serious complication that affects prognosis in this patient population. Malnutrition, critical status, and cardiovascular stress are additional predisposing factors in this fragile group. Driveline and surgery-associated infections are the most commonly identified culprits. However, decreased host immune function facilitates atypical infections including systemic fungemia and viremia. This case is an interesting example of a VAD associated immune system compromise.

High Right Atrial Pressure and Low Pulse Pressure PredictGastrointestinal Bleeding in Patients With Left Ventricular Assist Device

BACKGROUND Gastrointestinal bleeding (GIB) remains a major morbid event during continuous flow left ventricular assist device (LVAD) support. This study investigated whether a common hemodynamic profile is associated with GIB in patients with LVADs. METHODS AND RESULTS A single institution analysis reviewed all patients who underwent right heart catheterization (RHC) following LVAD implant between January 1, 2006, and December 31, 2013, with follow-up through June 2015. Kaplan-Meier and multiphase hazard statistical methods were employed. Among 108 patients with 341 RHC, 55 hospitalizations for GIB occurred within 1 year of RHC. Freedom from GIB at 6 months was 92% in patients with pulse pressure ≥35 mmHg, compared with 76% with pulse pressure <35 mmHg. By multivariable analysis, the significant predictors of GIB were: older age at implant, number of prior GIB, lower pulse pressure, lower mean arterial pressure, and higher right atrial pressure (all P < .05). The magnitude of effect is influenced by pulse pressure. CONCLUSIONS Greater pulsatility and less venous congestion, along with other factors, are associated with a lower risk for GIB. It is reasonable to adjust therapeutic strategies to target this hemodynamic profile in patients with a propensity for GIB.

Myocardial perfusion imaging for cardiac allograft vasculopathy assessment: Evidence grows, but questions remain

Cardiac allograft vasculopathy (CAV) is a leading cause of long-term mortality after heart transplantation. CAV can present insidiously because of denervation of the transplanted heart, and significant heart failure or sudden death can be the first presentation. The median survival of patients transplanted between 1992 and 2001 is 10.5 years. CAV develops in one-third of heart transplant survivors at 5 years and in one-half at 10 years post-transplant, and is responsible for at least 12.8% of deaths at 10 years. Risk factor modification and early therapy with mammalian target of rapamycin (mTOR) inhibitors such as sirolimus may attenuate CAV progression. Percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) are useful for focal lesions but suboptimal in advanced disease because of diffuse disease, poor targets, and high restenosis rates. Retransplantation is effective, but raises ethical concerns, is severely hampered by organ shortage, and requires planning and waiting during which time clinical events can occur. Therefore, early detection and formulation of strategies to prevent or treat CAV is important in optimizing overall outcomes after heart transplantation. Historically, coronary angiography (CAG) has been the preferred modality for CAV screening. However, there are many limitations of CAG, including invasiveness, risk of contrast nephropathy, and most importantly relative insensitivity to detect CAV given the diffuse nature of disease, inability to directly assess the intima, lack of a reference segment and microvascular involvement. Approximately 50% of heart transplant recipients develop renal dysfunction at 5 years post-transplant, and routine use of surveillance angiography becomes challenging. Patients with reportedly normal CAGs who died from graft failure have a high prevalence of significant CAV on autopsy. As a result, several other anatomic and functional, invasive and non-invasive modalities, including dobutamine stress echocardiography (DSE), myocardial perfusion imaging (MPI), positron emission tomography (PET), computed tomography (CT), Magnetic Resonance Imaging (MRI), intravascular ultrasound (IVUS), and optical coherence tomography (OCT), have been evaluated in CAV. The majority of these studies have been single-center, observational, with heterogeneous populations, differing methodologies, and only a few have evaluated long-term outcomes. In this issue of the Journal, Veenis and colleagues report on the long-term prognostic value of exercise/dobutamine 99mTc-tetrofosmin SPECT MPI performed at a mean time of 7.4 years post heart transplant in 166 patients between 1992 and 1998. The short-term results, published in 2002, found that routine clinical variables did not predict cardiac death, but peak rate-pressure product and abnormal myocardial perfusion were significant predictors of cardiac death at a median follow-up of 2.5 years post MPI. This study extended the follow-up to mean 9.5 years and concluded that patients with normal SPECT had lower major cardiac events up to 1 year after testing, lower cardiac mortality up to 2 years after testing, and lower all-cause mortality up to 5 years after testing compared to patients with abnormal SPECT. By multivariate analysis, the presence of a reversible perfusion defect was a predictor Reprint requests: Deepak Acharya, MD, MSPH, Section of Advanced Heart Failure, Transplantation, and Mechanical Circulatory Support, University of Alabama at Birmingham, 1900 University Blvd, THT 321, Birmingham, 35294; dacharya@uab.edu J Nucl Cardiol 2019;26:853–6. 1071-3581/

Adverse Events in Continuous-Flow LVAD Recipients: Gastrointestinal Bleeding is Still Notable?

34.00 Copyright 2017 American Society of Nuclear Cardiology.

INTERMACS Analysis of Stroke During Support With Continuous-Flow Left Ventricular Assist Devices: Risk Factors and Outcomes

Background The etiology and risk factors associated with gastrointestinal bleeding (GIB) in patients with continuous-flow left ventricular assist devices (CF-LVADs) are currently unknown. Therefore, we sought to assess the risk factors for GIB in these patients. Design and Methods