Jeffrey Alexis

Effect of metoprolol versus carvedilol on outcomes in MADIT-CRT (multicenter automatic defibrillator implantation trial with cardiac resynchronization therapy).

OBJECTIVES This study sought to compare the effects of metoprolol and carvedilol in the MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy) study. BACKGROUND The impact of beta-blockers in heart failure (HF) patients with devices is uninvestigated. METHODS All patients receiving either metoprolol or carvedilol in the MADIT-CRT study were identified and compared. Time-dependent Cox proportional hazard regression analyses were performed to assess differences in hospitalization for HF or death and ventricular arrhythmias. RESULTS Hospitalization for HF or death occurred in 30% of the patients on metoprolol and in 23% on carvedilol. Treatment with carvedilol was associated with a significantly decreased risk of hospitalization for HF or death when compared with metoprolol (hazard ratio [HR]: 0.70, [95% confidence interval (CI): 0.57 to 0.87], p = 0.001). This reduction in risk was further attenuated in the subgroup of cardiac resynchronization therapy with implantable cardioverter-defibrillator (CRT-D) patients (HR: 0.61 [95% CI: 0.46 to 0.82], p = 0.001) and CRT-D patients with left bundle branch block (LBBB) (HR: 0.51 [95% CI: 0.35 to 0.76], p < 0.001). Ventricular arrhythmias occurred in 26% and in 22%, respectively, of the patients receiving metoprolol or carvedilol (HR: 0.80 [95% CI: 0.63 to 1.00], p = 0.050). General use of beta-blockers and adherence in this study was high, and a clear dose-dependent relationship was found in carvedilol, but not in metoprolol. CONCLUSIONS In HF patients in New York Heart Association functional class I and II and with wide QRS complexes, carvedilol was associated with a 30% reduction in hospitalizations for HF or death when compared with metoprolol. A novel beneficial and synergistic effect of carvedilol was seen in patients with CRT-D and LBBB. Furthermore, we found a pronounced dose-dependent relationship in carvedilol, but not in metoprolol.

Diastolic function improvement is associated with favourable outcomes in patients with acute non-ischaemic cardiomyopathy: insights from the multicentre IMAC-2 trial

AIMS Patients with recent onset non-ischaemic cardiomyopathy have a variable clinical course with respect to recovery of left ventricular ejection fraction (LVEF). The aim of this study was to understand whether temporal changes in diastolic function (DF) are associated with clinical outcomes independent of LVEF recovery. METHODS AND RESULTS The Intervention in Myocarditis and Acute Cardiomyopathy (IMAC)-2 study was a prospective, multicentre trial investigating myocardial recovery in subjects with symptoms onset of <6 months and LVEF ≤40% of non-ischaemic dilated cardiomyopathy related to idiopathic cardiomyopathy or myocarditis. LVEF and DF were measured at presentation and at 6-month follow-up. Of 147 patients (mean age 46 ± 14 years, 40% female), baseline LVEF was 23 ± 8%. At 6 months, LVEF improved to 41 ± 12%, with 71% increasing by at least 10% ejection fraction units. DF improved in 58%, was unchanged in 28%, and worsened in 14%. Over a mean follow-up of 1.8 ± 1.2 years, there were 18 events: 11 heart failure (HF) hospitalizations, 3 deaths, and 4 heart transplants. LVEF (HR = 0.94, 95% CI 0.91-0.98, P = 0.002) and DF improvements at 6 months (HR = 0.32, 95% CI 0.11-0.92, P = 0.03) were independently associated with lower likelihood for the combined end point of death, transplantation, and HF hospitalization. Diastolic functional improvement at 6-month follow-up was as prognostically important as LVEF recovery for these patients, and provided incremental prognostic value to the risk stratification (X(2) increased from 12.6 to 18, P = 0.02). CONCLUSION In patients with recent onset non-ischaemic cardiomyopathy, DF recovery was associated with favourable outcomes independent of LVEF improvement, adding incremental prognostic value to these patients.

Prior hospital admission predicts thirty-day hospital readmission for heart failure patients.

BACKGROUND Hospital readmission is a significant health burden. More than 20% of heart failure (HF) patients are readmitted within 30 days of discharge leading to billions of dollars in health care expenditures. However, the role of prior hospital admissions to predict 30-day readmission for HF patients is not fully understood. METHODS We retrospectively analyzed HF hospitalization data for 4 years at a single medical center. Association between prior admission and 30-day readmission after HF hospitalization was assessed using a multivariate logistic regression model. RESULTS A total of 1,999 patients with index HF hospitalizations were identified, and 366 of them (18%) were readmitted within 30 days. The rate of readmission was 14%, 20%, and 33% in patients with 0, 1, ≥ 2 prior admissions. Patients with one prior admission had a 50% higher risk (confidence interval [CI] 1.10-2.05, p = 0.011) for readmission, while those with ≥ 2 prior admissions had a more than 3-fold increase in readmission (CI 2.27-4.09, p < 0.001), after adjustments for relevant clinical covariates. Prior hospital admission provided incremen-tal value in predicting readmissions, shown by the significant improvement in the readmission predictive model (C-statistics increased from 0.57 to 0.63). However, neither the length of stay nor recency of prior admission was a significant factor in predicting readmissions. CONCLUSIONS Hospital admission prior to an index HF hospitalization is associated with a significantly increased risk for 30-day hospital readmission and could be used to identify patients at high-risk for readmission and potentially target interventions to reduce the risk of readmission for these patients.

Echocardiographic detection of left ventricular thrombus in patients undergoing HeartMate II left ventricular assist device implantation

Purpose Transthoracic (TTE) and transesophageal echocardiograms (TEE) are considered accurate in detecting the presence of left ventricular (LV) thrombus. A persistent LV thrombus poses risks of pump thrombosis and stroke in LVAD recipients. The relationship between pre-operative echocardiography and intraoperative findings at LVAD implantation has not previously been studied. Methods A retrospective review examined all patients undergoing LVAD placement or exchange from October 2011 to March 2014. Pre-Operative TTE and TEE data were validated with presence of LV thrombus during the direct inspection at the time of LVAD placement, and the findings were analyzed quantitatively. Results Between October 2011 and March 2014, 99 patients underwent a total of 107 LVAD implants. Pre-Operative TTE was available in 93 (86.9%) cases, while pre-operative TEE was available in 37 cases (34.6%). On pre-operative TTE, LV thrombus was correctly identified in only two cases, while on pre-operative TEE no cases of LV thrombus were identified correctly, and there were 2 false positive reports. Intraoperative inspection revealed presence of LV thrombus in 14 cases. The sensitivity of pre-operative TTE was 16.7% and the specificity 100% in detecting LVT, compared to 0% and 93.8%, respectively, for TEE. Conclusions Pre-Operative echocardiogram offers low accuracy for presence of LV thrombus. Overall, the sensitivity is too low to reliably exclude thrombus. This could have significant implications in planning off-pump LVAD exchange as thrombus could be missed. More data are necessary to determine whether this could have significant effects on thromboembolic complications and survival.

Feasibility of transfemoral hepatic vein/wedged portal venous pressure measurement in total artificial heart

The development of technology and limitation of numerous ventricular assist devices has increased usage of the total artificial heart (TAH) for mechanical circulatory support. A primary important feature of TAH is that it is one of the few mechanical circulatory support devices that provides biventricular support. As the number of patients with TAH rises, spreading awareness about the device in the interventional radiology community is important.

Renal Function Changes Following Left Ventricular Assist Device Implantation

Limited data assessing the clinical significance of post-left ventricular assist device (LVAD) in renal function are available. We aimed to investigate the impact of changes in renal function after LVAD implantation on subsequent long-term outcomes. We followed 184 patients with HeartMate II LVADs implanted between May 2008 and November 2014. Serial assessment of renal function, was performed at baseline and at day 1, day 7, 1 month, 3 months, 6 months, 1 year, and 2 years after implantation. Effects of 1-month GFR and changes in GFR from baseline to 1 month on long-term mortality and hospital re-admission were evaluated. There were 30 patients with GFR <45 (low), 44 with GFR 45 to 59 (intermediate), and 110 with GFR ≥60 (normal) at baseline. Only patients with baseline GFR <45 experienced significant improvement in GFR after 2 years of follow-up (p = 0.012). At 1 month, a higher GFR category was significantly associated with a 31% reduction in mortality (hazard ratio [HR] 0.69, CI 0.49 to 0.98, p = 0.036), but not re-admission. Patients with baseline low and intermediate GFR who had no improvement in renal function category at 1 month experienced significantly greater risk of mortality (HR 1.95, CI 1.10 to 3.43, p = 0.022) and re-admission (HR 1.75, CI 1.07 to 2.84, p = 0.025), relative to patients whose GFR was normal at baseline and 1 month. In conclusion, renal function after LVAD implantation improves in patients with GFR <45. Change in renal function from baseline to 1 month after implantation is a powerful marker of long-term outcomes.

PRE-OPERATIVE PULMONARY FUNCTION TESTS AND OUTCOMES AMONG PATIENTS RECEIVING LEFT VENTRICULAR ASSIST DEVICES

The pulmonary function test (PFT) is a component of evaluation for left ventricular assist device (LVAD) implantation. Our aim was to assess the effect of pre-operative lung function on outcomes after LVAD placement. We retrospectively studied 153 patients who received HeartMate II devices at our