Joyce Wald

Extracorporeal life support as rescue strategy for out-of-hospital and emergency department cardiac arrest.

BACKGROUND Extracorporeal life support (ECLS) has been utilized as a rescue strategy for patients with cardiac arrest unresponsive to conventional cardiopulmonary resuscitation. OBJECTIVE We sought to describe our institutions experience with implementation of ECLS for out-of-hospital and emergency department (ED) cardiac arrests. Our primary outcome was survival to hospital discharge. METHODS Consecutive patients placed on ECLS in the ED or within one hour of admission after out-of-hospital or ED cardiac arrest were enrolled at two urban academic medical centers in the United States from July 2007-April 2014. RESULTS During the study period, 26 patients were included. Average age was 40±15 years, 54% were male, and 42% were white. Initial cardiac rhythms were ventricular fibrillation or pulseless ventricular tachycardia in 42%. The average time from initial cardiac arrest to initiation of ECLS was 77 ± 51 min (range 12-180 min). ECLS cannulation was unsuccessful in two patients. Eighteen (69%) had complications related to ECLS, most commonly bleeding and ischemic events. Four patients (15%) survived to discharge, three of whom were neurologically intact at 6 months. CONCLUSION ECLS shows promise as a rescue strategy for refractory out-of-hospital or ED cardiac arrest but is not without challenges. Further investigations are necessary to refine the technique, patient selection, and ancillary therapeutics.

Managing Heart Failure Care Using an Internet-Based Telemedicine System

BACKGROUND Managing patients with heart failure (HF) is labor intensive, and follow-up is often inadequate to detect day-to-day changes that ultimately lead to decompensation. We tested the effect of an Internet-based telemedicine (T) system that provides frequent surveillance and increased communicate between HF patients and their provider on frequency of hospitalization in a cohort of patients with advanced HF. METHODS AND RESULTS HF patients in NYHA Class II-IV were randomized to usual care (UC, n = 24) or T (T plus UC, n = 24) and followed for 1 year. Office visits, emergency department visits, hospitalizations, telephone calls, and number of Internet communications were measured over the 1-year period. Left ventricular ejection fraction (EF) was assessed by echocardiography in both groups. For T, mean age was 53.2 +/- 2.0 years (72% male, 61% Caucasian, 39% African American). For UC, mean age was 54.1 +/- 2.6 years (76% male, 72% Caucasian, 14% African American, and 14% Hispanic). HF etiologies and EF were similar in both groups. During the 12-month period, UC had 74 total phone calls to the practice, whereas T had 88 telephone calls plus 1887 telemedicine data messages (6.5 messages/patient/month). ER visits were lower in the T group (T 5, UC 12; P < .05). Hospital admissions (T 24, C 40; P = .025) and total hospital days (T 84, UC 226 days; P < .005) were lower in T. Unscheduled clinic visits (T 13, UC 13; P = NS) and scheduled clinic visits (T 78, UC 94; P = NS) were similar in both groups. CONCLUSIONS Frequent monitoring and patient management using a telemedicine system may help to reduce hospitalizations, hospital days, and emergency department visits.

Clinical outcomes after cardiac transplantation in muscular dystrophy patients

BACKGROUND Patients with muscular dystrophy are at risk of developing a dilated cardiomyopathy and can progress to advanced heart failure. At present, it is not known whether such patients can safely undergo cardiac transplantation. METHODS This was a retrospective review of the Cardiac Transplant Research Database, a multi-institutional registry of 29 transplant centers in the United States, from the years 1990 to 2005. The post-cardiac transplant outcomes of 29 patients with muscular dystrophy were compared with 275 non-muscular dystrophy patients with non-ischemic cardiomyopathy, matched for age, body mass index, gender, and race. RESULTS Beckers muscular dystrophy was present in 52% of the patients. Survival in the muscular dystrophy patients was similar to the controls at 1 year (89% vs 91%; p = 0.5) and at 5 years (83% vs 78%; p = 0.5). The differences in rates of cumulative infection, rejection, or allograft vasculopathy between the 2 groups were not significant (p > 0.5 for all comparisons). CONCLUSIONS Recognizing the limitations of the present investigation (ie, selection bias and data lacking in the functional capacity of the muscular dystrophy patients), the current study suggests that the clinical outcomes after cardiac transplantation in selected patients with muscular dystrophy are similar to those seen in age-matched patients with non-ischemic cardiomyopathy.

Management of the sensitized cardiac recipient : the use of plasmapheresis and intravenous immunoglobulin

Abstract:  Previously, we reported that the combination of plasmapheresis (PP) and intravenous immunoglobulin (IVIg) allow sensitized patients to undergo orthotopic heart transplantation (OHT), even across a positive crossmatch. In the current study, the effect of that combination, PP +IVIg, on survival of a larger group of such recipients is investigated. The latter group (I) consisted of 35 sensitized patients who received PP + IVIG together with standard immunosuppressive drugs. Rejection was seen in 11 patients, findings strongly suggestive of a vascular (humoral) being identified in five of those cases. Four deaths occurred, two of them in the immediate post‐operative period, one after almost six months, and one after almost two yr post‐OHT. Follow‐up range 4.5 months to 7.8 yr post‐OHT (average = 1.1 yr). Patient survival was analyzed after generation of a Kaplan–Meier plot. Comparison with a control OHT group (II) given standard immunosuppressive drugs only (N = 276) showed enhanced survival of group I (p = 0.0414 by log‐rank test). We conclude that the combination of PP and IVIG (i) is associated with declines in T‐ and B‐percent‐reactive antibody and in crossmatch positivity, and (ii) is very useful in the management of the sensitized cardiac patient undergoing OHT, often allowing a successful outcome to transplantation in the face of a positive crossmatch.

Correlation of circulating donor-specific anti-HLA antibodies and presence of C4d in endomyocardial biopsy with heart allograft outcomes: A single-center, retrospective study

BACKGROUND Donor-specific antibodies (DSA) are associated with increased cardiac graft loss and cardiac vasculopathy (CAV). Detection of antibody-mediated rejection (AMR) relies on graft dysfunction, C4d immunofluorescence (IF) and DSA. METHODS We retrospectively studied the relationship of DSA, endomyocardial biopsy (EMB) and C4d IF to cardiac transplant outcomes. DSA were evaluated against HLA class I and II specificities, both pre- and post-transplant, using microbead-based assays. RESULTS Of 626 cardiac transplant patients, 109 with concurrent EMBs and C4d IF and DSA measurement were included in this study. In patients with and without DSA, CAV occurred in 31% and 13% and acute cellular rejection (ACR) in 100% and 84%, respectively. One hundred ten of 170 EMBs procured during episodes of graft dysfunction had concurrent DSA. In these patients, C4d IF correlated better with DSA to class I or both class I and II and less so in patients with DSA to class II. Graft failure (GF) rates of 40%, 29% and 58% with average times to GF of 33, 77 and 48 months were seen in patients with DSA to class I, II or both, respectively. CONCLUSIONS Patients with DSA to class I or to both class I and II showed a correlation with C4d IF and had higher GF rates compared to patients with DSA to only class II or no DSA; patients with DSA to class II remained at risk for CAV. Episodes of ACR and CAV, but not AMR, appeared to be more frequently associated with graft dysfunction in patients with circulating DSA.

Trends in U.S. Extracorporeal Membrane Oxygenation Use and Outcomes: 2002-2012

This study evaluates contemporary trends in the use and outcomes of adult patients undergoing extracorporeal membrane oxygenation (ECMO) in U.S. hospitals. All adult discharges in the Nationwide Inpatient Sample database during the years 2002-2012 that included ECMO were used to estimate the total number of U.S. ECMO hospitalizations (n = 12,407). Diagnostic codes were used to group patients by indication for ECMO use into postcardiotomy, heart transplant, lung transplant, cardiogenic shock, respiratory failure, and cardiopulmonary failure. A Mann-Kendall test was used to examine trends over time using standard statistical techniques for survey data. We found that ECMO use increased significantly from 2002-2012 (P = 0.003), whereas in-hospital mortality rate fluctuated without a significant difference in trend over time. No significant trend was observed in overall ECMO use from 2002-2007, but the use did demonstrate a statistically significant increase from 2007-2012 (P = 0.0028). The highest in-hospital mortality rates were found in the postcardiotomy (57.2%) and respiratory failure (59.2%) groups. Lung and heart transplant groups had the lowest in-hospital mortality rates (44.10% and 45.31%, respectively). The proportion of ECMO use for postcardiotomy decreased from 56.9% in 2002 to 37.9% in 2012 (P = 0.026) and increased for cardiopulmonary failure from 3.9% to 11.1% (P = 0.026). We concluded that ECMO use in the United States increased between 2002 and 2012, driven primarily by increase in national ECMO use beginning in 2007. Mortality rates remained high but stable during this time period. Though there were shifts in relative ECMO use among patient groups, absolute ECMO use increased for all indications over the study period.

Circulating donor-specific anti-human leukocyte antigen antibodies and complement C4d deposition are associated with the development of cardiac allograft vasculopathy.

BACKGROUND Cardiac allograft vasculopathy (CAV) continues to be a limiting factor in long-term survival of heart transplant recipients (HTRs). Pathophysiologic and immunologic factors affecting CAV are complex, and criteria for early diagnosis remain elusive. METHODS We performed a retrospective analysis of the relationship between donor-specific antibody (DSA), C4d immunofluorescence, and the development of CAV. RESULTS We evaluated 330 endomyocardial biopsy (EMB) specimens from 112 cardiac grafts. Twenty-four (21%) of 112 grafts developed CAV, and 18 (75%) of 24 were positive for C4d. Patients with DSA (n = 51) against human leukocyte antigen class I (n = 5), II (n = 26), or both (n = 20) developed CAV at a rate of 40%, 38%, and 20% and a mean time to CAV of 89, 47, and 25 months, respectively. Of 61 grafts without DSA, only 13% developed CAV, with a mean time to CAV of 116 months. CONCLUSIONS Compared with the general HTR population, patients with graft dysfunction and DSA or positive C4d on EMB show a statistically significant increased incidence of CAV and allograft failure, suggesting an antibody-mediated injury. The presence of pre- and posttransplant DSA, even in the absence of positive C4d immunofluorescence, may identify a group of HTRs at increased risk of developing CAV.

Trends in mechanical circulatory support use and hospital mortality among patients with acute myocardial infarction and non-infarction related cardiogenic shock in the United States

BackgroundRecent trends on outcomes in cardiogenic shock (CS) complicating acute myocardial infarction (AMI) suggest improvements in early survival. However, with the ever-changing landscape in management of CS, we sought to identify age-based trends in these outcomes and mechanical circulatory support (MCS) use among patients with both AMI and non-AMI associated shock.MethodsWe queried the 2005–2014 Nationwide Inpatient Sample databases to identify patients with a diagnosis of cardiogenic shock. Trends in the incidence of hospital-mortality, and use of MCS such as intra-aortic balloon pump (IABP), Impella/TandemHeart (IMP), and extra corporeal membrane oxygenation (ECMO) were analyzed within the overall population and among different age-categories (50 and under, 51–65, 66–80 and 81–99 years). We also made comparisons between patient groups admitted with CS complicating AMI and those with non-AMI associated CS.ResultsWe studied 144,254 cases of CS, of which 55.4% cases were associated with an AMI. Between 2005 and 2014, an overall decline in IABP use (29.8–17.7%; ptrend < 0.01), and an uptrend in IMP use (0.1–2.6%; ptrend < 0.01), ECMO use (0.3–1.8%; ptrend < 0.01) and in-hospital mortality (44.1–52.5% AMI related, 49.6–53.5% non-AMI related; ptrend < 0.01) was seen. Patients aged 81–99 years had the lowest rate of MCS use (14.8%), whereas those aged 51–65 years had highest rate of MCS use (32.3%). Multivariable analysis revealed that patients aged 51-65 years (aOR 1.46, 95% CI 1.40–1.52; p<0.001), 66–80 years (aOR 2.51, 95% CI 2.39–2.63; p<0.01) and 81–99 years (aOR 5.04, 95% CI 4.78–5.32; p<0.01) had significantly higher hospital mortality compared to patients aged ≤ 50 years. Patients admitted with CS complicating AMI were older and had more comorbidities, but lower hospital mortality (45.0 vs. 48.2%; p < 0.001) when compared to non-AMI related CS. We also noted that the proportion of patients admitted with CS complicating AMI significantly decreased from 2005 to 2014 (65.3–45.6%; ptrend < 0.01) whereas those admitted without an associated AMI increased.ConclusionsIABP use has declined whereas IMP and ECMO use has increased over time among CS admissions. Older age was associated with an incrementally higher independent risk for hospital mortality. Recent trends indicate an increase in both proportion of patients admitted with CS without associated AMI and in-hospital mortality across all CS admissions irrespective of AMI status.

Racial Differences in Clinical Treatment and Self‐Care Behaviors of Adults With Chronic Heart Failure

Background In the United States, the highest prevalence of heart failure (HF) is in blacks followed by whites. Compared with whites, blacks have a higher risk of HF‐related morbidity and mortality and HF‐related hospitalization. Little research has focused on explaining the reasons for these disparities. The purpose of this study was to examine racial differences in demographic and clinical characteristics in blacks and whites with HF and to determine if these characteristics influenced treatment, or together with treatment, influenced self‐care behaviors. Methods and Results This was a secondary analysis of existing data collected from adults (n=272) with chronic HF enrolled from outpatient sites in the northeastern United States and followed for 6 months. After adjusting for sociodemographic and clinical characteristics within reduced (HFrEF) and preserved ejection fraction (HFpEF) groups, there were 2 significant racial differences in clinical treatment. Blacks with HFrEF were prescribed ACE inhibitors and hydralazine and isosorbide dinitrate (H‐ISDN) more often than whites. In the HFpEF group, blacks were taking more medications and were prescribed digoxin and a diuretic when symptomatic. Deficits in HF knowledge and decreased medication adherence, objectively measured, were more prominent in blacks. These racial differences were not explained by sociodemographic or clinical characteristics or clinical treatment variables. Premorbid intellect and the quality of support received contributed to clinical treatment and self‐care. Conclusion Although few differences in clinical treatment could be attributed solely to race, knowledge about HF and medication adherence is lower in blacks than whites. Further research is needed to explain these observations, which may be targets for future intervention research.

Successful cardiac transplantation outcomes in patients with adult congenital heart disease

Objectives The purpose of our study is (1) to characterise patients with congenital heart disease undergoing heart transplantation by adult cardiac surgeons in a large academic medical centre and (2) to describe successful outcomes associated with our multidisciplinary approach to the evaluation and treatment of adults with congenital heart disease (ACHD) undergoing orthotopic heart transplantation (OHT). Background Heart failure is the leading cause of death in patients with ACHD leading to increasing referrals for OHT. Methods The Penn Congenital Transplant Database comprises a cohort of patients with ACHD who underwent OHT between March 2010 and April 2016. We performed a retrospective cohort study of the 20 consecutive patients. Original cardiac diagnoses include single ventricle palliated with Fontan (n=8), dextro-transposition of the great arteries after atrial switch (n=4), tetralogy of Fallot (n=4), pulmonary atresia (n=1), Ebstein anomaly (n=1), unrepaired ventricular septal defect (n=1) and Noonan syndrome with coarctation of the aorta (n=1). Results Eight patients required pretransplant inotropes and two required pretransplant mechanical support. Nine patients underwent heart–liver transplant and three underwent heart–lung transplant. Three patients required postoperative mechanical circulatory support. Patients were followed for an average of 38 months as of April 2016, with 100% survival at 30 days and 1 year and 94% overall survival (19/20 patients). Conclusions ACHD–OHT patients require highly specialised, complex and multidisciplinary healthcare. The success of our programme is attributed to using team-based, patient-centred care including our multidisciplinary staff and specialists across programmes and departments.