José González-Costello

Prevalence, Significance, and Management of Aortic Insufficiency in Continuous Flow Left Ventricular Assist Device Recipients

Background— Aortic insufficiency (AI) is increasingly recognized as a complication of continuous flow left ventricular assist device support; however, its long-term prevalence, clinical significance, and efficacy of potential interventions are not well known. Methods and Results— We studied the prevalence and management of AI in 232 patients with continuous flow left ventricular assist device at our institution. Patients with aortic valve (AV) surgery before left ventricular assist device implantation were excluded from analysis. To examine the prevalence of de novo AI, patients without preoperative AI were divided into a retrospective and a prospective cohort based on whether a dedicated speed optimization study had been performed at the time of discharge. Forty-three patients underwent AV repair at the time of implant, and 3 subsequently developed greater than mild AI. In patients without surgical AV manipulation and no AI at the time of implant, Kaplan–Meier analysis revealed that freedom from greater than mild de novo AI at 1 year was 77.6±4.2%, and that at least moderate AI is expected to develop in 37.6±13.3% after 3 years. Nonopening of the AV was strongly associated with de novo AI development in patients without prospective discharge speed optimization. Seven of 21 patients with at least moderate AI developed symptomatic heart failure requiring surgical intervention. Conclusions— AI is common in patients with continuous flow left ventricular assist devices and may lead to clinical decompensation requiring surgical correction. The prevalence of AI is substantially less in patients whose AV opens, and optimized loading conditions may reduce AI prevalence in those patients in whom AV opening cannot be achieved.

Human immunodeficiency virus infection and left ventricular assist devices: a case series.

Historically, advanced heart failure therapies were considered inappropriate for patients infected with human immunodeficiency virus (HIV). As HIV has become a chronic illness with the advent of highly active anti-retroviral therapy (HAART), cardiac transplantation has been used for selected HIV patients with end-stage heart failure. We present a case series describing the clinical outcomes with left ventricular assist device (LVAD) use in 4 patients with HIV. Three of the patients are alive: 1 after a successful bridge to transplant and the other 2 on continued device support at 18 and 13 months after implantation. No infectious complications occurred in 3 patients, and no opportunistic infections occurred in the fourth patient. De novo allosensitization did not occur in our patients after LVAD implantation. With the ongoing donor shortage, implantation of an LVAD in advanced heart failure patients with HIV with controlled viremia on HAART represents a viable option.

Twelve hours of sustained ventricular fibrillation supported by a continuous-flow left ventricular assist device.

Left ventricular assist device (LVAD) therapy improves survival and quality of life by mechanically unloading the left ventricle and maintaining hemodynamics in patients with end‐stage heart failure. LVADs can also be lifesaving by maintaining hemodynamics during ventricular arrhythmia. Continuous‐flow LVADs have become the preferred LVAD technology. As presented here, a continuous‐flow LVAD successfully provided hemodynamic support to a patient in sustained ventricular fibrillation for over 12 hours when the internal defibrillator was unable to terminate the arrhythmia. This case demonstrates that continuous‐flow LVADs can be lifesaving in the setting of otherwise certain hemodynamic collapse from sustained ventricular fibrillation. (PACE 2012; 35:e144–e148)

Ventricular assist device support as a bridge to heart transplantation in patients with giant cell myocarditis

Giant cell myocarditis (GCM) carries a poor prognosis and many patients require end‐stage therapies. This study sought to determine the outcome of patients bridged with ventricular assist devices (VAD) to orthotopic heart transplantation (OHT).

Clinical outcomes of temporary mechanical circulatory support as a direct bridge to heart transplantation: a nationwide Spanish registry

In Spain, listing for high‐urgent heart transplantation is allowed for critically ill candidates not weanable from temporary mechanical circulatory support (T‐MCS). We sought to analyse the clinical outcomes of this strategy.

Bridging cardiogenic shock patients with short-term ventricular support at a community hospital to long-term ventricular support at a tertiary hospital

BACKGROUND Patients in cardiogenic shock require immediate circulatory support. Outcomes of patients who underwent short-term ventricular assist device (STVAD) implantation in a community hospital (CH) as a bridge to a long-term VAD (LTVAD) were compared with those who received both implants at the same tertiary hospital (TH). METHODS Data were retrospectively reviewed for patients with a STVAD who were bridged to a LTVAD in a TH from 1997 to 2010. We studied outcomes and survival censored for cardiac transplantation. RESULTS Thirty-seven patients (73% male) were identified. Mean age was 52 ± 16 years, 30% were diabetic, and 65% had intra-aortic balloon pump support. Reasons for STVAD implantation were an acute myocardial infarction, 38%; post-cardiotomy, 38%, decompensated chronic heart failure, 19%; and others, 5%. A STVAD was implanted in a CH in 20 patients (54%), and they had fewer cardiovascular risk factors than those whose STVAD was implanted at the TH. All patients at the CH were at Interagency Registry for Mechanically Assisted Circulatory Support 1 compared with 71% at the TH (p = 0.014). Patients from the CH tended to die sooner after LTVAD implant, although long-term survival was similar. At the 1-year follow-up, 65% from the CH were alive or had received a transplant vs 60% from the TH. CONCLUSION Patients with cardiogenic shock in whom a STVAD was implanted in a CH and then were bridged to a LTVAD in a TH had similar long-term survival as those bridged to LTVAD at the TH.

The effect of lung volume reduction surgery on chronotropic incompetence

BACKGROUND Chronotropic incompetence (CI) is a marker of poor prognosis in patients with COPD. Treatments that improve pulmonary function and exercise capacity may affect CI. Objectives are to evaluate CI before and after lung volume reduction surgery (LVRS) and determine if changes in CI are associated with changes in pulmonary function and exercise capacity. METHODS We performed a retrospective review of 75 patients who underwent LVRS and who had complete cardiopulmonary exercise testing and concurrent pulmonary function tests two months before and about 6 months after surgery. Additionally we evaluated 28 control patients that were randomized to medical treatment as part of the National Emphysema Treatment Trial at our center. We studied CI using the percent of predicted heart rate reserve=(heart rate peak-heart rate rest)/((208-0.7×age)-heart rate rest)×100, before and after surgery and compared it to the control group. RESULTS Mean percent of predicted heart rate reserve improved from 41% to 50% (p-value <0.001) after LVRS, while the control group did not change. The mean forced vital capacity and expiratory volume in 1s, peak oxygen consumption, carbon dioxide production, ventilation, tidal volume and maximal workload all improved in the surgery group, while the controls did not improve. CONCLUSIONS CI improves after LVRS in a population of patients with COPD. CI improvements are associated with the increases in pulmonary function and exercise capacity. This improvement is seen in a domain of known cardiopulmonary impairment prior to surgery that improves as a positive response to the therapy of LVRS.

Adrenergic Activation, Fuel Substrate Availability, and Insulin Resistance in Patients With Congestive Heart Failure

OBJECTIVES This study sought to investigate plasma levels of glucose and free fatty acids (FFA) and their relationship with adrenergic activation and insulin resistance (IR) in patients with advanced congestive heart failure (CHF). BACKGROUND Adrenergic activation and IR are hallmarks of advanced heart failure. The resulting changes in fuel substrate availability and their implications for exercise capacity have not been elucidated. METHODS Subjects with CHF underwent maximal exercise testing. Plasma glucose, FFA, insulin, and norepinephrine (NE) levels were measured at rest and at peak exercise. Beta-receptor sensitivity to NE was assessed using the Chronotropic Responsiveness Index (CRI). Homeostasis Model Assessment Index >2.5 defined IR. Left ventricular ejection fraction was estimated by 2-dimensional echocardiography. RESULTS Ninety-six subjects were enrolled. CHF subjects without IR (CHF/No-IR), but not those with IR (CHF/IR), significantly increased glucose and insulin in response to exercise. Only CHF/No-IR subjects increased FFA in response to exercise (0.14 ± 0.27 mmol/l; p = 0.027). NE increased significantly less with exercise, and CRI was lower in CHF/IR subjects compared with CHF/No-IR subjects (1.3 ± 1.4 vs. 2.5 ± 2.1; 6.4 ± 2.6 vs. 8.5 ± 3.4; p = 0.069). CRI correlated with the exercise-induced increase in FFA (r = 0.41; p < 0.005). These results stayed the same after excluding diabetic patients from the CHF/IR group. CONCLUSIONS Circulating FFA levels increased during exercise in CHF subjects without IR, but not in those with IR or DM. Increased FFA availability during exercise may represent a catecholamine-dependent compensatory fuel shift in CHF.

Chronotropic incompetence predicts mortality in severe obstructive pulmonary disease.

We evaluated the prevalence of chronotropic incompetence (CI), a marker of autonomic dysfunction, and its prognostic value in patients with chronic obstructive pulmonary disease (COPD). We performed a retrospective analysis of 449 patients with severe COPD who underwent a cardiopulmonary exercise test, after excluding patients with lung volume reduction surgery, left ventricular dysfunction and those not in sinus rhythm. CI was defined as percent predicted heart rate reserve (%HRR). Events were defined as death or lung transplant during a median follow-up of 68 months. Median age was 61 years; median percent predicted forced expiratory volume in one second (%FEV1) of 25% and median %HRR of 33%. The hazard ratio for an event in the lowest quartile of %HRR, taking the highest quartile as reference, was of 3.2 (95% confidence interval: 2.1-4.8; p<0.001). In a multivariate regression model, %HRR was an independent predictor of events. In conclusion, CI was an independent and powerful outcome predictor in patients with severe COPD.

Preoperative Toxoplasma gondii serostatus does not affect long-term survival of cardiac transplant recipients. Analysis of the Spanish Heart Transplantation Registry

BACKGROUND Its unclear whether pre-transplant T. gondii seropositivity is associated with impaired survival in heart transplant recipients. OBJECTIVES To test the above-mentioned hypothesis in the Spanish Heart Transplantation Registry. METHODS Post-transplant outcomes of 4048 patients aged >16years who underwent first, single-organ heart transplantation in 17 Spanish institutions from 1984 to 2014 were studied. Long-term post-transplant survival and survival free of cardiac death or retransplantation of 2434 (60%) T. gondii seropositive recipients and 1614 (40%) T. gondii seronegative recipients were compared. RESULTS T. gondii seropositive recipients were older, had higher body mass index, and presented higher prevalence of hypertension, hypercholesterolemia, COPD and Cytomegalovirus seropositivity than T. gondii seronegative recipients. In univariable analysis, pre-transplant T. gondii seropositivity was associated with increased post-transplant all-cause mortality (non-adjusted HR 1.15; 95% CI 1.04-1.26). However, this effect was no longer statistically significant after multivariable adjustment by recipients age and sex (adjusted HR 1.01, 95% CI 0.92-1.11). Extended multivariable adjustment by other potential confounders showed similar results (adjusted HR 0.99, 95% CI 0.89-1.11). T. gondii seropositivity had no significant effect on the composite outcome cardiac death or retransplantation (non-adjusted HR 1.08, 95% CI 0.95-1.24, p=0.235). The distribution of the causes of death was comparable in T. gondii seropositive and T. gondii seronegative recipients. No statistically significant impact of donors T. gondii serostatus or donor-recipient T. gondii serostatus matching on post-transplant survival was observed. CONCLUSIONS Our analysis did not show a significant independent effect of preoperative T. gondii serostatus on long-term outcomes after heart transplantation.