Jooyoung Shin

Readmissions After Ventricular Assist Device: Etiologies, Patterns, and Days Out of Hospital

BACKGROUND Scarce literature exists describing the patterns of readmission after continuous flow left ventricular assist device (CF-LVAD) implantation. These carry significant cost and quality of life implications. We sought to describe the etiology and pattern of readmission among patients receiving CF-LVADs. METHODS Frequency, reason, urgency, and duration of readmission as well as freedom from readmission were examined in a retrospective review of our institutional experience. As an indirect means of quality of life, the ratio of days out of hospital (OOH)/days alive with device was calculated. RESULTS From 2006 to 2011, 71 adult patients implanted with a CF device were included. Indication for device implantation was bridge to transplant (n=19), potential bridge to transplant (n=25), or destination therapy (n=27). Length of support averaged 359 days. Total support time was 69.7 patient years. One hundred fifty-five readmissions accounted for a total of 1,659 hospital days. Fifty-six patients were readmitted during the study period. Median time to first readmission was 48 days (range 2 to 663 days). Median length of stay was 5 days. The single most common etiology for readmission was gastrointestinal bleeding accounting for 14% of readmissions. Readmissions were urgent (87%), elective (10%), or life-threatening (3%). Patients on the average enjoyed 92% of their time OOH. CONCLUSIONS Patients undergoing CF-LVAD support are often readmitted within 6 months of discharge. Readmissions tend to be of short duration and the most common reason is for gastrointestinal bleeding. Importantly, following discharge after implant procedure, 51 patients spent at least 90% of days OOH.

Outcomes of cardiac transplantation in septuagenarians

BACKGROUND Cardiac transplantation in many centers is programmatically limited to patients aged younger than 70 years. We investigated the trends and outcomes for cardiac transplantation in recipients aged 70 years and older in the United States. METHODS De-identified data were provided by United Network of Organ Sharing. Transplant recipients were grouped by age 60-69 years and 70 years and older. Univariate comparisons were performed using Students t-test or the Pearson chi-square test. Survival was estimated using the Kaplan-Meier technique and compared with the log-rank test. Cox regression was used to determine predictors of death after transplant. Statistical significance was assigned to p < 0.05. RESULTS Between January 1, 1998, and June 15, 2010, 5,807 sexagenarians and 332 septuagenarians received allografts. The septuagenarian cohort had more men, less diabetes, was less likely to have a ventricular assist device, and more likely to be status II. Donors for septuagenarians were older and died more frequently from intracranial hemorrhage. Median unadjusted survival was 9.8 years for sexagenarians vs 8.5 years for septuagenarians (p = 0.003). There was no difference in the incidence of cerebrovascular accident, length of stay, or pacemaker need between groups. Septuagenarians were less likely to be treated for rejection the first year (p = 0.001). Age was a multivariate predictor of death (hazard ratio, 1.289; 95% confidence interval, 1.039-1.6; p = 0.021). CONCLUSIONS Selected septuagenarians with advanced heart failure can derive great benefit from cardiac transplantation, although survival is inferior to that of an immediately younger sexagenarian cohort. Most of the mortality risk is seen in the first year after transplantation. A reduced incidence of rejection was observed and warrants further study.

Frailty Assessment in Advanced Heart Failure

BACKGROUND Several studies have recently demonstrated the value of frailty assessment in a general heart failure (HF) population; however, it is unknown whether these findings are also applicable in advanced HF. We investigated the utility of frailty assessment and its prognostic value in elderly patients with advanced HF. METHODS Forty consecutive elderly subjects aged ≥65 years, with left ventricular ejection fraction ≤35%, New York Heart Association class III or IV, and a 6-minute walk test <300 m were enrolled from the HF clinic at Montefiore Medical Center between October 2012 and July 2013. Subjects were assessed for frailty with the Fried Frailty Index, consisting of 5 components: hand grip strength, 15-foot walk time, weight loss, physical activity, and exhaustion. All subjects were prospectively followed for death or hospitalization. RESULTS At baseline, the mean age of the cohort was 74.9 ± 6.5 years, 58% female, left ventricular ejection fraction 25.6 ± 6.4%, 6-minute walk test 195.8 ± 74.3 m and length of follow-up 454 ± 186 days. Thirty-five percent were prefrail and 65% were frail. Frailty status was associated with the combined primary endpoint of mortality and all-cause hospitalization (hazard ratio [HR] 1.93, 95% confidence interval [CI] 1.15-3.25, P = .013). On individual analysis, frailty was associated with all-cause hospitalizations (HR 1.92, 95% CI 1.12-3.27, P = .017) and non-HF hospitalizations (HR 3.31, 95% CI 1.14- 9.6, P = .028), but was not associated with HF hospitalizations alone (HR 1.31, 95% CI 0.68-2.49, P = .380). CONCLUSIONS Frailty assessment in patients with advanced HF is feasible and provides prognostic value. These findings warrant validation in a larger cohort.

Improved Exercise Performance and Skeletal Muscle Strength After Simulated Altitude Exposure: A Novel Approach for Patients With Chronic Heart Failure

BACKGROUND Adaptation to altitude leads to beneficial physiologic changes that improve oxygen delivery and utilization by the periphery. Athletes have used simulated altitude enclosures as part of their training regimen to improve exercise performance. We hypothesized that changes due to acclimatization would also be beneficial for patients with heart failure (HF). We report the results of a pilot study of altitude exposure in patients with chronic HF. METHODS AND RESULTS Subjects with chronic stable HF, left ventricular ejection fraction (LVEF) ≤35%, on optimal medical therapy were enrolled and underwent simulated altitude exposure for 10 sessions, each 3-4 hours, over a period of 22 days. Starting altitude was 1,500 m and was increased by 300 m with each subsequent session to a maximum altitude of 2,700 m. Peak oxygen consumption, 6-minute walk distance (6MW), skeletal muscle strength, quality of life scores, LVEF, and hematologic parameters were measured at baseline and 48 hours and 4 weeks after the final session. Twelve subjects (median age 52.5 y, ejection fraction 31.7%) successfully completed the protocol without any adverse effects. Peak oxygen consumption significantly improved after altitude sessions from 13.5 ± 1.8 to 14.2 ± 1.9 mL kg(-1) min(-1) (P = .036) and remained elevated after 4 weeks. There were significant improvements in exercise time, 6MW, skeletal muscle strength, and quality of life scores and a trend toward improvement in LVEF after completion of altitude sessions, which were sustained after 1 month. CONCLUSIONS Simulated altitude exposure up to 2,700 m is safe and well tolerated in patients with chronic stable HF and may have beneficial effects on exercise performance, muscular strength, and quality of life.

Donor Troponin and Survival after Cardiac Transplantation: An Analysis of the United Network of Organ Sharing Registry

Background— Despite a limited supply of organs, only 1 in 3 potential donor hearts is accepted for transplantation. Elevated donor troponin levels have generally been considered a contraindication to heart transplantation; however, the data supporting this practice are limited. Methods and Results— We identified 10 943 adult (≥18 years) heart transplant recipients in the United Network of Organ Sharing (UNOS) database with preserved donor left ventricular ejection fraction (≥50%) and where peak donor troponin I values were available. When analyzed as a continuous variable, there was no association between peak donor troponin levels and recipient mortality up to 1 year follow-up in unadjusted (hazards ratio, 0.999; 95% confidence interval, 0.997–1.002; P =0.856) and adjusted Cox models (hazards ratio, 1.000; 95% confidence interval, 0.997–1.002; P =0.950). Next, we divided the entire cohort into 3 groups based on donor troponin I values: 10 ng/mL (n=361). Using unadjusted and adjusted Cox models and Kaplan–Meier analysis, there was no significant difference in recipient mortality at 30 days, 1 year, 3 years, or 5 years between the 3 groups. Similarly, cardiac allograft vasculopathy up to 5 years and primary graft failure up to 30 days of follow-up post transplant did not differ between the 3 donor troponin groups. The median length of hospital stay post transplant was also similar across groups. Conclusions— Elevated donor troponin I levels in the setting of preserved left ventricular ejection fraction were not associated with intermediate-term mortality, cardiac allograft vasculopathy, or primary graft failure rates in hearts accepted for transplantation. This finding could help expand the donor pool.Background—Despite a limited supply of organs, only 1 in 3 potential donor hearts is accepted for transplantation. Elevated donor troponin levels have generally been considered a contraindication to heart transplantation; however, the data supporting this practice are limited. Methods and Results—We identified 10 943 adult (≥18 years) heart transplant recipients in the United Network of Organ Sharing (UNOS) database with preserved donor left ventricular ejection fraction (≥50%) and where peak donor troponin I values were available. When analyzed as a continuous variable, there was no association between peak donor troponin levels and recipient mortality up to 1 year follow-up in unadjusted (hazards ratio, 0.999; 95% confidence interval, 0.997–1.002; P=0.856) and adjusted Cox models (hazards ratio, 1.000; 95% confidence interval, 0.997–1.002; P=0.950). Next, we divided the entire cohort into 3 groups based on donor troponin I values: <1 ng/mL (n=7812), 1 to 10 ng/mL (n=2770), and >10 ng/mL (n=361). Using unadjusted and adjusted Cox models and Kaplan–Meier analysis, there was no significant difference in recipient mortality at 30 days, 1 year, 3 years, or 5 years between the 3 groups. Similarly, cardiac allograft vasculopathy up to 5 years and primary graft failure up to 30 days of follow-up post transplant did not differ between the 3 donor troponin groups. The median length of hospital stay post transplant was also similar across groups. Conclusions—Elevated donor troponin I levels in the setting of preserved left ventricular ejection fraction were not associated with intermediate-term mortality, cardiac allograft vasculopathy, or primary graft failure rates in hearts accepted for transplantation. This finding could help expand the donor pool.

Association of centre volume and in-hospital mortality in heart failure hospitalisations

Background Centre volume is an important determinant of outcomes in patients requiring complex medical treatments or surgical procedures. Heart failure hospitalisation (HFH) has become an increasingly complex and resource intensive clinical event. We evaluated the effect of centre volume on mortality and costs in patients with HFH. Methods This was a retrospective registry-based analysis of adult patients discharged with a primary diagnosis of HF from hospitals across New York (NY) State over a 5-year period, between January 2009 and December 2013, using the Statewide Planning and Research Cooperative System inpatient discharge files. The primary outcome of interest was in-hospital mortality. All patients were followed from the day of admission to either in-hospital death or discharge alive. Results 300 972 HFHs from 198 facilities across NY State were included. Five-year centre volume was associated with a decrease in in-hospital mortality in unadjusted (HR=0.872, 95% CI 0.863 to 0.881, p<0.001) and adjusted Cox models (HR=0.869, 95% CI 0.859 to 0.879, p<0.001). After dividing the overall cohort into three groups based on 5-year centre volume, groups with medium and high volume centres had lower in-hospital mortality when compared with the group with low volume centres. The results were consistent in various subgroup analyses. Furthermore, hospitals in the higher centre volume groups had increased HFH costs across different severity of illness categories and involved increased use of cardiac procedures. Conclusions Higher centre volume was associated with lower HFH mortality but increased HFH costs and increased cardiac procedures in a cohort of Medicare and non-Medicare beneficiaries.

Spontaneous coronary artery dissection in a postpartum e-cigarette smoker

Spontaneous coronary artery dissection (SCAD) is a rare but lethal cause of acute coronary syndrome that occurs in young women during the peripartum/postpartum periods. We present a case of a 41-year-old woman with no significant medical history, but was a habitual e-cigarette smoker who presented with atypical chest pain 2 weeks after an uncomplicated delivery while breast feeding. The patient was found to have elevated cardiac enzymes and ST segment elevations in the anterior leads. An urgent cardiac catheterisation was performed, which revealed dissection and occlusion of the left anterior descending artery, and a drug-eluting stent was placed that resulted in the resolution of chest pain. Physiological changes during the postpartum period may be linked to an increased risk of developing SCAD.1 In addition, e-cigarette smoking is associated with increased oxidative stress and sympathetic activity, which may predispose patients to an increased risk of acute coronary syndrome.

Heart Failure Management and Development of Heart Failure Programs

Advances in the treatment of HF and early interventions to prevent clinical decompensation delay disease progression and improve survival. After initial evaluation and the implementation of guideline-directed medical therapy, outpatient HF management strategies focus on the maintenance of patient stability. Multidisciplinary disease-management HF programs may help improve HF patient outcomes, including decreased symptoms, improved quality of life, reduced rates of hospital admission, and decreased healthcare costs. The principals of effective HF care include: a patient-centered multidisciplinary approach, rigorous adherence to evidence-based treatment through written protocols, early detection of exacerbations, development of individualized management plans, promotion of patient self-management, continuity of care, and continuous monitoring of program outcomes and quality improvement.

HIGH CENTER VOLUME IS ASSOCIATED WITH LOWER IN-HOSPITAL MORTALITY IN HEART FAILURE PATIENTS: A NEW YORK STATE WIDE ANALYSIS OF 300,000 ADMISSIONS

Center volume is a determinant of outcomes in patients requiring complex medical treatments. We evaluated the effect of center volume on in-hospital mortality in patients with a primary discharge diagnosis of heart failure (HF). A retrospective analysis of adult patients with a primary discharge

Donor Troponin and Survival After Cardiac TransplantationCLINICAL PERSPECTIVE

Background— Despite a limited supply of organs, only 1 in 3 potential donor hearts is accepted for transplantation. Elevated donor troponin levels have generally been considered a contraindication to heart transplantation; however, the data supporting this practice are limited. Methods and Results— We identified 10 943 adult (≥18 years) heart transplant recipients in the United Network of Organ Sharing (UNOS) database with preserved donor left ventricular ejection fraction (≥50%) and where peak donor troponin I values were available. When analyzed as a continuous variable, there was no association between peak donor troponin levels and recipient mortality up to 1 year follow-up in unadjusted (hazards ratio, 0.999; 95% confidence interval, 0.997–1.002; P =0.856) and adjusted Cox models (hazards ratio, 1.000; 95% confidence interval, 0.997–1.002; P =0.950). Next, we divided the entire cohort into 3 groups based on donor troponin I values: 10 ng/mL (n=361). Using unadjusted and adjusted Cox models and Kaplan–Meier analysis, there was no significant difference in recipient mortality at 30 days, 1 year, 3 years, or 5 years between the 3 groups. Similarly, cardiac allograft vasculopathy up to 5 years and primary graft failure up to 30 days of follow-up post transplant did not differ between the 3 donor troponin groups. The median length of hospital stay post transplant was also similar across groups. Conclusions— Elevated donor troponin I levels in the setting of preserved left ventricular ejection fraction were not associated with intermediate-term mortality, cardiac allograft vasculopathy, or primary graft failure rates in hearts accepted for transplantation. This finding could help expand the donor pool.Background—Despite a limited supply of organs, only 1 in 3 potential donor hearts is accepted for transplantation. Elevated donor troponin levels have generally been considered a contraindication to heart transplantation; however, the data supporting this practice are limited. Methods and Results—We identified 10 943 adult (≥18 years) heart transplant recipients in the United Network of Organ Sharing (UNOS) database with preserved donor left ventricular ejection fraction (≥50%) and where peak donor troponin I values were available. When analyzed as a continuous variable, there was no association between peak donor troponin levels and recipient mortality up to 1 year follow-up in unadjusted (hazards ratio, 0.999; 95% confidence interval, 0.997–1.002; P=0.856) and adjusted Cox models (hazards ratio, 1.000; 95% confidence interval, 0.997–1.002; P=0.950). Next, we divided the entire cohort into 3 groups based on donor troponin I values: <1 ng/mL (n=7812), 1 to 10 ng/mL (n=2770), and >10 ng/mL (n=361). Using unadjusted and adjusted Cox models and Kaplan–Meier analysis, there was no significant difference in recipient mortality at 30 days, 1 year, 3 years, or 5 years between the 3 groups. Similarly, cardiac allograft vasculopathy up to 5 years and primary graft failure up to 30 days of follow-up post transplant did not differ between the 3 donor troponin groups. The median length of hospital stay post transplant was also similar across groups. Conclusions—Elevated donor troponin I levels in the setting of preserved left ventricular ejection fraction were not associated with intermediate-term mortality, cardiac allograft vasculopathy, or primary graft failure rates in hearts accepted for transplantation. This finding could help expand the donor pool.