J.J. Shin

Combining neurohormonal blockade with continuous-flow left ventricular assist device support for myocardial recovery: A single-arm prospective study

BACKGROUNDnCombining mechanical unloading by a continuous-flow left ventricular assist device (CF-LVAD) and neurohormonal blockade with heart failure medications (HFMED) is an underexplored clinical strategy to promote recovery of cardiac function in patients with advanced heart failure (HF).nnnMETHODSnWe implemented a clinical protocol to achieve maximal neurohormonal blockade after placement of a CF-LVAD and assessed its utility in an LVAD weaning (6,200 rpm) study. Thirty-four subjects were enrolled after CF-LVAD and were managed with aggressive, bi-weekly up-titration of HFMED.nnnRESULTSnTwenty-one subjects (8 with coronary artery disease, 13 with idiopathic dilated cardiomyopathy) were included in this LVAD weaning investigation. Overall, combined CF-LVAD and HFMED resulted in significant reverse remodeling with a decrease in left atrial volume index (44.7±16.0 to 31.6±12.1 ml/m(2), p < 0.001) and LV internal diastolic diameter (6.7±1.5 to 6.0±1.6 cm, p = 0.003) and an increase in LV ejection fraction (17.4±6.5 to 33.1±16.2%, p < 0.001) during LVAD weaning (6,200 rpm). Five of 21 (24%) subjects demonstrated recovery of biventricular function. Exploratory analysis showed that recovered subjects had shorter duration HF, less myocardial fibrosis and less myocyte hypertrophy, and were supported at higher LVAD speeds.nnnCONCLUSIONSnCF-LVAD support in combination with HFMED leads to significant reverse remodeling in patients with advanced HF. Using this approach, one quarter of patients demonstrated complete recovery of cardiac function. Our results suggest that bridge to recovery in the current device era is a clinically meaningful phenomenon and merits further investigation.

Hospital mortality and thirty day readmission among patients with non-acute myocardial infarction related cardiogenic shock

BACKGROUNDnCardiogenic shock (CS) in absence of acute myocardial infarction (AMI) has significant morbidity and mortality. This population of patients has been excluded from prior major randomized trials and observational studies.nnnMETHODSnWe included patients with CS in absence of AMI from the 2013-14 HCUPs National Readmission Database. 30-day readmissions were studied and etiology for readmission was identified by using ICD-9CM codes in primary diagnosis field. Multivariable mixed effect logistic regression models were created to identify predictors of 30-day readmission and in-hospital mortality, respectively.nnnRESULTSnWe studied 38,198 index admissions with non-AMI CS, with an in-hospital mortality of 35.4%. Mean age, length and cost of stay were 63.6u202fyears, 16.9u202fdays and 69,947

Impact of Device Design and Patient Management on the Incidence of Neurologic Events after HVAD Left Ventricular Assist Device

, respectively among survivors of index admission. Among those discharged, 22.6% were readmitted within 30u202fdays with >50% readmissions occurring within 11-days. Cardiovascular etiologies (42.3%), especially heart failure (24.0%) comprised the commonest reason for readmission. Among non-cardiac causes were infectious (11.7%) and respiratory (9.2%) etiologies. Older age (50-64u202fyears odds ratio:1.29, 65-79u202fyears, OR:1.59, ≥80u202fyears OR:2.69), ventilator use (OR:4.25), sepsis (OR:1.12), use of short term devices (intra-aortic balloon pump OR:2.67, Impella/TandemHeart OR:4.84, extracorporeal membrane oxygenation OR:3.68) and non-ischemic cardiomyopathy(OR:0.65) were among the predictors of in-hospital mortality. Older age (65-79u202fyears, OR:1.25, ≥80u202fyears OR:1.41), male sex (OR:1.08), and ventilator use (OR:1.21) predicted higher 30-day readmission.nnnCONCLUSIONnBoth, in-hospital mortality and 30-day readmission among those admitted for non-AMI CS were significantly elevated. The majority of readmissions were due to non-cardiovascular causes. Identifying high-risk factors may help devise strategies to improve quality of care and reduce adverse outcome rates.