Jamie L.W. Kennedy

Significantly Higher Rates of Gastrointestinal Bleeding and Thromboembolic Events With Left Ventricular Assist Devices

BACKGROUND & AIMSnThe risk of gastrointestinal (GI) bleeding (GIB) and thromboembolic events may increase with continuous-flow left ventricular assist devices (CF-LVADs). We aimed to characterize GIB and thromboembolic events that occurred in patients with CF-LVADs and compare them with patients receiving anticoagulation therapy.nnnMETHODSnWe performed a retrospective analysis of 159 patients who underwent CF-LVAD placement at 2 large academic medical centers (mean age, 55 ± 13 y). We identified and characterized episodes of GIB and thromboembolic events through chart review; data were collected from a time period of 292 ± 281 days. We compared the rates of GIB and thromboembolic events between patients who underwent CF-LVAD placement and a control group of 159 patients (mean age, 64 ± 15 y) who received a cardiac valve replacement and were discharged with anticoagulation therapy.nnnRESULTSnBleeding events occurred in 29 patients on CF-LVAD support (18%; 45 events total). Sixteen rebleeding events were identified among 10 patients (range, 1-3 rebleeding episodes/patient). There were 34 thrombotic events among 27 patients (17%). The most common source of bleeding was GI angiodysplastic lesions (nxa0= 20; 44%). GIB and thromboembolic events were more common in patients on CF-LVAD support than controls; these included initial GIB (18% vs 4%, Pxa0<xa0.001), rebleeding (6% vs none, P = .001), and thromboembolic events (17% vs 8%, P = .01).nnnCONCLUSIONSnPatients with CF-LVADS receiving anticoagulants have a significantly higher risk of GIB and thromboembolic events than patients receiving anticoagulants after cardiac valve replacement surgery. GI angiodysplastic lesions are the most common source of bleeding.

The role of methylene blue in serotonin syndrome following cardiac transplantation: a case report and review of the literature.

References 1. Pennathur A, Luketich JD, Abbas G, Chen M, Fernando HC, Gooding WE, et al. Radiofrequency ablation for the treatment of stage I non-small cell lung cancer in high-risk patients. J Thorac Cardiovasc Surg. 2007;134:857-64. 2. Lanuti M, Sharma A, Digurmarthy SR, Wright CD, Donahue DM, Wain JC, et al. Radiofrequency ablation for treatment of medically inoperable stage I non-small cell lung cancer. J Thorac Cardiovasc Surg. 2009;137:160-6. 3. Schneider T, Reuss D, Warth A, Schnabel PA, Von Deimling A, Herth FJF, et al. The efficacy of bipolar and multipolar radiofrequency ablation of lung neo-

Effects of early inhaled epoprostenol therapy on pulmonary artery pressure and blood loss during LVAD placement.

OBJECTIVEnSeveral strategies have been used to reduce the incidence of right ventricular failure after left ventricular assist device (LVAD) placement, including pulmonary vasodilation. The inhaled prostacyclin, epoprostenol, selectively dilates the pulmonary vasculature of ventilated areas of the lung, but also has been shown to inhibit platelet aggregation.(1) The authors evaluated the impact of early initiation of epoprostenol administration during LVAD placement on pulmonary artery pressures, use of vasoactive drugs, and blood loss.nnnDESIGNnRetrospective data review.nnnSETTINGnSingle center, university hospital.nnnPARTICIPANTSnA total of 37 consecutive patients undergoing LVAD (HeartMate II) placement were included.nnnINTERVENTIONSnIn the first group of 23 patients (group 1), inhaled epoprostenol was not initiated until weaning from cardiopulmonary bypass (CPB). In a subsequent group of 14 patients (group 2), inhaled epoprostenol was started shortly after induction of anesthesia and continued throughout and post-CPB.nnnMEASUREMENTSnMean and systolic pulmonary artery pressures (mPAP, sPAP), vasoactive drugs, as well as hemodynamic parameters, blood loss, and use of blood products were recorded at the following time points: Baseline (BL), pre-CPB, post-CPB, and during postoperative days (POD) 0, 1, and 2. Data are presented as mean±SD or median [25%, 75%].nnnRESULTSnGroups did not differ in demographic characteristics and comorbidities. BL sPAP (41±13 v 46±15 mmHg; p = 0.051) and mPAP (32±8 v 34±8 mmHg; p = 0.483) values were not different between the groups. Systolic and mPAP in group 1 were significantly lower in the postoperative period compared with BL (sPAP on POD 0: 34±6 mmHg; p<0.001; mPAP on POD 0, 1, and 2: 24±4 mmHg, 25±4 mmHg, 27±6 mmHg; p<0.001-0.003)). In contrast, in group 2, sPAP as well as mPAP were significantly lower during weaning from CPB (sPAP: 37±8; p = 0.002; mPAP: 28±5 mmHg; p = 0.016) as well as in the postoperative period (sPAP on POD 0, 1 and 2: 34±7, 35±7, and 37±10 mmHg; p<0.001-0.004; mPAP on POD 0, 1, and 2: 24±4 mmHg, 25±5 mmHg, 27±6 mmHg; p<0.001-0.006). Blood loss on postoperative day 0 was significantly lower in group 1 (1646 mL [1137, 2300] v 2915 mL [2335, 6155]; p = 0.006). Epoprostenol was a significant predictor of blood loss in the regression model (p<0.001) but did not predict a change in sPAP.nnnCONCLUSIONSnInhaled prostacyclin reduces sPAP and mPAP in the postoperative period after LVAD placement regardless of the timing of initiation. Early initiation seems to reduce sPAP as well as mPAP more effectively during the weaning process from CPB. However, early initiation is associated with an increased blood loss in the immediate postoperative period. The concept of preventively bathing the lung in prostacyclin should be evaluated critically in a prospective fashion to adequately examine this question.

Obesity paradox in group 1 pulmonary hypertension: analysis of the NIH-Pulmonary Hypertension registry

Background:The ‘obesity paradox’ refers to the fact that obese patients have better outcomes than normal weight patients. This has been observed in multiple cardiovascular conditions, but evidence for obesity paradox in pulmonary hypertension (PH) remains sparse.Methods:We categorized 267 patients from the National Institute of Health-PH registry into five groups based on body mass index (BMI): underweight, normal weight, overweight, obese and morbidly obese. Mortality was compared in BMI groups using the χ2 statistic. Five-year probability of death using the PH connection (PHC) risk equation was calculated, and the model was compared with BMI groups using Cox proportional hazards regression and Kaplan–Meier (KM) survival curves.Results:Patients had a median age of 39 years (interquartile range 30–50 years), a median BMI of 23.4u2009kgu2009m−2 (21.0–26.8u2009kgu2009m−2) and an overall mortality at 5 years of 50.2%. We found a U-shaped relationship between survival and 1-year mortality with the best 1-year survival in overweight patients. KM curves showed the best survival in the overweight, followed by obese and morbidly obese patients, and the worst survival in normal weight and underweight patients (log-rank P=0.0008). In a Cox proportional hazards analysis, increasing BMI was a highly significant predictor of improved survival even after adjustment for the PHC risk equation with a hazard ratio for death of 0.921 per kgu2009m−2 (95% confidence interval: 0.886–0.954) (P<0.0001).Conclusion:We observed that the best survival was in the overweight patients, making this more of an ‘overweight paradox’ than an ‘obesity paradox’. This has implications for risk stratification and prognosis in group 1 PH patients.

2141 A novel approach for screening atherosclerosis in diabetes: MRI of the superficial femoral artery

Introduction Peripheral arterial disease (PAD) has a high prevalence (29%) in asymptomatic patients with diabetes mellitus (DM) with a significantly increased risk of cardiovascular events and morbidity. Current screening methods are inadequate. The superficial femoral artery (SFA) may be a relatively accessible target for screening of atherosclerosis. Cardiovascular magnetic resonance (CMR) allows direct visualization of atherosclerotic plaque burden noninvasively. We sought to establish the prevalence of peripheral atherosclerosis in a cohort of asymptomatic patients with diabetes and coronary artery disease by CMR of the SFA.

COST ANALYSIS OF HEART FAILURE READMISSION INTERVENTION PROGRAM

Dedicated heart failure (HF) clinics have been established to improve HF care. The Hospital-to-Home (H2H) program at our institution is a rapid clinic follow-up program for patients with recent HF admissions. We evaluated the real world costs of health care delivery with H2H after a HF admission

High-resolution T1 mapping with ANGIE detects increased right-ventricular extracellular volume fraction in patients with pulmonary arterial hypertension

Background Right ventricular (RV) failure is associated with increasing morbidity and mortality in pulmonary arterial hypertension (PAH). Pressure overload in PAH leads to a complex series of changes in cardiomyocytes and the extracellular matrix of the RV. Thus, quantitative T1 mapping of the RV to assess myocardial extracellular volume fraction (ECV) may be a valuable noninvasive marker of RV fibrosis in these patients. However, current clinically preferred T1 mapping techniques have limited spatial resolution, restricting their application to assessment of left ventricular (LV) ECV. We recently developed a novel technique, termed ANGIE, which uses navigator gating and acceleration with compressed sensing (CS) to provide high-resolution T1 mapping for assessment of thin structures such as the wall of the RV. The aim of the present study was to use ANGIE to test the hypothesis that RV ECV is elevated in patients with PAH compared to reference subjects.

Pulmonary-Systemic Pressure Ratio Correlates with Morbidity in Cardiac Valve Surgery

OBJECTIVESnPulmonary hypertension portends worse outcomes in cardiac valve surgery; however, isolated pulmonary artery pressures may not reflect patients global cardiac function accurately. To better account for the interventricular relationship, the authors hypothesized that patients with greater pulmonary-systemic ratios (mean pulmonary arterial pressure)/(mean systemic arterial pressure) would correlate with worse outcomes after valve surgery.nnnDESIGNnRetrospective cohort study.nnnSETTINGnSingle academic hospital.nnnPARTICIPANTSnThe study comprised 314 patients undergoing valve surgery with or without coronary artery bypass grafting (2004-2016) with Society of Thoracic Surgeons predicted risk scores and preoperative right heart catheterization.nnnINTERVENTIONSnNone.nnnMEASUREMENTS AND MAIN RESULTSnThe pulmonary-systemic ratio was calculated as follows: mean pulmonary arterial pressure/mean systemic arterial pressure. Patients were stratified by pulmonary-systemic ratio quartile. Logistic regression was used to assess the risk-adjusted association between pulmonary-systemic ratio or mean pulmonary arterial pressure. Median pulmonary-systemic ratio was 0.33 (Q1-Q3: 0.23-0.65); median pulmonary arterial pressure was 29 (21-30) mmHg. Patients with the highest pulmonary-systemic ratio had the highest rates of morbidity and mortality (p < 0.0001). A high pulmonary-systemic ratio was associated with longer duration in the intensive care unit (p < 0.0001) and hospital (p < 0.0001). After risk-adjustment, pulmonary-systemic ratio and pulmonary arterial pressure were independently associated with morbidity and mortality, but the pulmonary-systemic ratio (odds ratio 23.88, pu202f=u202f0.008, Wald 7.1) was more strongly associated than the pulmonary arterial pressure (odds ratio 1.035, pu202f=u202f0.011, Wald 6.5).nnnCONCLUSIONSnThe pulmonary-systemic ratio is more strongly associated with risk-adjusted morbidity and mortality in valve surgery than pulmonary arterial pressure. By integrating ventricular interactions, this metric may better characterize the risk of valve surgery.

IMPACT ON READMISSIONS AND MORTALITY OF HEART FAILURE READMISSION INTERVENTION PROGRAM

Heart failure (HF) readmissions are a quality measure for health outcomes. The Hospital-to-Home (H2H) program is an institutional rapid clinic follow-up program for patients with HF admission. We sought to determine the impact of this intervention on HF readmissions and mortality during the first 30