Juan G. Duero Posada

The prognostic significance of frailty compared to peak oxygen consumption and B-type natriuretic peptide in patients with advanced heart failure

Frailty assessment has become an integral part of the evaluation of potential candidates for heart transplantation and ventricular assist device (HTx/VAD). The impact of frailty, as a heart failure risk factor or to identify those who will derive the greatest benefit with HTx/VAD remains unclear. The aim of this study was to evaluate the independent prognostic relevance of frailty assessment from peak oxygen consumption (peak VO2) or B‐type natriuretic peptide (BNP) on mortality in patients referred for advanced heart failure therapies. Frailty was measured using modified Fried frailty criteria. In 201 consecutive patients, during a median follow‐up of 17.5 months (IQR 11‐29.2), there were 25 (12.4%) deaths. One‐year survival was 100%, 94%, and 78% in nonfrail, prefrail, and frail patients, respectively (log rank P = .0001). Frailty was associated with a twofold increase risk of death (HR 2.01, P < .0001, 95% CI 1.42‐2.84). When adjusted for BNP or peak VO2, frailty was not associated with a significant risk of all‐cause death. However, when peak VO2 is stratified into two categories (≥12 mL/kg/min vs <12 mL/kg/min), frailty was associated with increased mortality in patients with a lower peak VO2 (HR 1.72, P = .006).

Outflow Graft Occlusion of the HeartMate 3 Left Ventricular Assist Device

Continuous-flow ventricular assist devices have demonstrated clinical superiority compared with the first-generation pulsatile devices; however, complications continue to affect patients on left ventricular assist device (LVAD) support.1 The recently published MOMENTUM 3 trial (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate3) reported that the HeartMate 3 (HM3) was associated with better outcomes after 6 months when compared with the HM2. None of the patients randomized to the HM3 device had suspected or confirmed thrombosis.2 In this brief report, we describe 2 patients who developed extrinsic occlusion of the outflow graft after HM3 implantation. A 65-year-old man with ischemic cardiomyopathy underwent implantation of an HM3 LVAD as bridge to transplantation. Because of significant epistaxis, acetylsalicylic acid was reduced from 325 to 81 mg daily, whereas international normalized ratio was maintained between 2 and 3. One-year post-LVAD, the patient presented with congestive symptoms and deteriorating renal function. His LVAD had logged multiple low-flow alarms, as low as 1.9 L/min (previously 4–4.5 L/min; Figure [C]). Serum lactate dehydrogenase was 290 U/L (125–220 U/L) and international normalized ratio maintained within therapeutic range. A noncontrast computed tomographic scan of the chest showed no …

Ventricular Thrombosis Post-Venoarterial Extracorporeal Membrane Oxygenation

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for the support of critically ill patients with cardiogenic shock is rapidly increasing. Intracardiac thrombus formation is a well-recognized complication. We present 3 cases of dramatic intracardiac thrombosis after the initiation of VA-ECMO. A 64-year-old man presented to a community hospital 3 days after the onset of chest pain with ECG evidence of anterior ST-elevation–myocardial infarction and clinical findings of cardiogenic shock. Physical examination was notable for a pansystolic murmur suggestive of a ventricular septal defect. Coronary angiography showed an occluded left anterior descending artery. Echocardiography confirmed an ischemic ventricular septal defect. He was taken urgently to the operating room for aortocoronary bypass and ventricular septal defect patch repair. Attempts to wean off cardiopulmonary bypass were unsuccessful, and the patient was placed on central VA-ECMO as a bridge to decision, with the chest left open. Forty-eight hours after the initiation of ECMO, the circuit was converted to a peripheral set-up to facilitate chest closure. Transesophageal echocardiogram performed 24 hours after chest closure showed complete thrombosis of the right ventricle despite full anticoagulation (Figure [A]; Movie I in the Data Supplement). He was taken back …

A local quality initiative to improve follow-up times for patients with heart failure

Introduction Heart failure is the most common cause of hospital admission in patients >65 years and around 50% of patients will be readmitted within 6 months. Inability to achieve timely outpatient follow-up may contribute to the high rates of avoidable rehospitalisation for this group of patients. Canadian guidelines recommend patients with heart failure should be seen within 14 days of discharge. Methods An audit demonstrated that less than half of advanced heart failure patients were being followed up within 14 days. In an effort to improve postdischarge follow-up in our heart function clinic, we used process mapping and applied a series of iterative changes to the appointment booking system using Plan–Do–Study–Act cycles to reduce waste and standardise. Results The primary outcome measure, tracked over a period of 20 months, was percentage of patients booked within 14 days. At baseline, 37% of patients were seen within 14 days. After our series of interventions related to streamlining and standardising the appointment booking process, 77% of patients were seen within 14 days and 100% of patients were seen within 21 days. Conclusion The changes made to the appointment booking process were reproducible, sustainable, effective and required no additional resources or funding.

Early pneumopericardium after heart transplantation

A 60‐year‐old woman with a history of dilated cardiomyopathy underwent heart transplantation. One month post discharge, she presented to clinic with low‐grade fever and productive cough. Her chest radiograph showed air‐fluid levels in the pericardial silhouette. Transthoracic echocardiogram showed a large complex pericardial collection with no evidence of cardiac tamponade. The patient was urgently taken to the operating room for exploration. A large “egg‐shaped” mass in the pericardium measuring 10 × 12 cm with gaseous material was aspirated. As the posterior wall of the mass was firmly adhered to the right atrium, the capsule was incompletely excised. We present the case of a potentially life‐threatening complication post transplantation that required surgical debridement and life‐long antibiotic suppressive therapy. To our knowledge, this is the first report of purulent pericardial collection caused by Enterobacter cancerogenous. Further research is required to better understand the biology of this microorganism and the role it may play as a pathogen in immunocompromised patients following solid organ transplantation.

Clustered Emergency Room Visits Following an Acute Heart Failure Admission: A Population‐Based Study

Background While it is well known that heart failure patients presenting to the emergency room (ER) have high short‐term mortality after discharge, the outcomes of patients with heart failure with repeated ER visits within a short time are not known. In this study, we aimed to determine whether clustering is associated with an increased risk of death. Methods and Results This is a retrospective, population‐based cohort study with an accrual window between 2003 and 2014 and maximal follow‐up up to and including March 31, 2015. Data were obtained from administrative databases from Ontario, Canada. Clustering was defined a priori as 3 or more ER visits within a 6‐month period. The main outcome of interest was time to death conditional on 6‐month survival. A total of 72 810 patients with an index hospitalization for acute heart failure were evaluated. ER clustering was observed in 15.1% of the population. Increased burden of comorbidities, primary rural residence, and lack of primary care provider were identified as factors associated with ER clustering. Age‐ and sex‐adjusted mortality for clustered patients was higher than for nonclustered (hazard ratio [HR] 1.51; 95% confidence interval, 1.47–1.55, P<0.0001). Adjusted mortality risk was also higher for patients with clustered ER visits (HR 1.42; 95% confidence interval 1.38–1.46; P<0.0001). Conclusions Clustering, as defined by 3 or more ER visits for any reason within 6 months of index heart failure hospitalization reflects a novel risk factor associated with increased mortality. Future research into the strategies to better manage complex patients with heart failure with recurrent ER visits are warranted.

Risk evaluation using gene expression screening to monitor for acute cellular rejection in heart transplant recipients

BACKGROUND Gene expression profiling (GEP) was developed for non-invasive surveillance of acute cellular rejection. Despite its widespread use, there has been a paucity in outcome data for patients managed with GEP outside of clinical trials. METHODS The Outcomes AlloMap Registry (OAR) is an observational, prospective, multicenter study including patients aged ≥ 15 years and ≥ 55 days post-cardiac transplant. Primary outcome was death and a composite outcome of hemodynamically significant rejection, graft dysfunction, retransplantation, or death. Secondary outcomes included readmission rates and development of coronary allograft vasculopathy and malignancies. RESULTS The study included 1,504 patients, who were predominantly Caucasian (69%), male (74%), and aged 54.1 ± 12.9 years. The prevalence of moderate to severe acute cellular rejection (≥2R) was 2.0% from 2 to 6 months and 2.2% after 6 months. In the OAR there was no association between higher GEP scores and coronary allograft vasculopathy (p = 0.25), cancer (p = 0.16), or non-cytomegalovirus infection (p = 0.10). Survival at 1, 2, and 5 years post-transplant was 99%, 98%, and 94%, respectively. The composite outcome occurred in 103 patients during the follow-up period. GEP scores in dual-organ recipients (heart-kidney and heart-liver) were comparable to heart-alone recipients. CONCLUSIONS This registry comprises the largest contemporary cohort of patients undergoing GEP for surveillance. Among patients selected for GEP surveillance, survival is excellent, and rates of acute rejection, graft dysfunction, readmission, and death are low.

Correction: Assessing the Use of Wrist-Worn Devices in Patients with Heart Failure: Feasibility Study

[This corrects the article DOI: 10.2196/cardio.8301.].

Letter by Moayedi et al Regarding Article, “Gene Expression Profiling for the Identification and Classification of Antibody-Mediated Heart Rejection”

We commend the authors of “Gene Expression Profiling for the Identification and Classification of Antibody-Mediated Heart Rejection” in a recent issue of Circulation. 1 The authors have begun the remarkable task of addressing the knowledge gap related to antibody mediated rejection (AMR), moving away from educated guesswork to precision medicine. We have come …