Julie Creaser

Relationship between right and left-sided filling pressures in 1000 patients with advanced heart failure.

BACKGROUND Elevated left ventricular filling pressures present a major target of therapy for symptomatic heart failure but are difficult to assess directly. Because the relationship of left- and right-sided pressures remains ill defined in chronic heart failure, this study compared 3 right-sided measurements (right atrial [RA] pressure, pulmonary artery systolic [PAS] pressure, and severity of tricuspid regurgitation [TR]) to the pulmonary capillary wedge (PCW) pressure. METHODS Hemodynamic measurements and echocardiography were available from 1000 patients undergoing transplant evaluation. Right atrial and PAS pressure, and TR severity were compared to PCW pressure. For 754 patients undergoing repeat measurements, changes in RA and PAS pressures were compared to PCW changes. RESULTS Right atrial pressure correlated with PCW pressure (r = 0.64), regardless of etiology or TR severity. Right atrial pressure changes correlated with PCW changes (r = 0.62). Discordance was defined as either RA > or = 10 mm Hg despite PCW < 22 mm Hg (6%) or RA < 10 mm Hg despite PCW > or = 22 mm Hg (15%). For detection of PCW > or = 22 mm Hg, positive predictive values were 88% for RA > or = 10 mm Hg, 95% for PAS > or = 60 mm Hg, and 79% for > or = moderate TR. Pulmonary artery systolic pressure correlated very closely with PCW (r = 0.79), and could be estimated as 2 x PCW. Reduction in PAS pressure during therapy was strongly determined by PCW pressure reduction (r = 0.67). CONCLUSIONS Accurate estimation of RA pressure can potentially guide therapy of left ventricular filling pressures in approximately 80% of chronic heart failure patients without obvious non-cardiac disease. In this population, elevated PAS pressures are largely determined by elevated left-sided filling pressures.

Target Heart Failure Populations for Newer Therapies

BACKGROUND The scarcity of donor hearts has created a large population of heart failure patients who are unlikely to undergo transplantation. Newer surgical therapies that might sustain such patients at home previously have been applied in critical situations in which early outcome is jeopardized by multiorgan failure. The optimal population for studies of extended support would be ambulatory patients with low operative risk but high risk of later unfavorable outcome. METHODS AND RESULTS Baseline clinical, echocardiographic, and hemodynamic data were collected prospectively between 1988 and 1993 in 500 patients who were discharged on tailored medical therapy after evaluation for transplantation. Specific criteria were examined to identify high risk of death or need for urgent transplantation during the next 2 years. In 265 patients with ejection fraction < or = 25% and initial New York Heart Association class IV symptoms, survival at 2 years was 55% (without urgent transplantation, 45%). Lower cardiac index or higher filling pressures at the time of referral did not confer higher risk, which was predicted by persistence of higher pressures after therapy. Serum sodium below 133 was associated with 34% 2-year survival without urgent transplantation, and ventricular dimension > 80 mm with a rate of 25%. Patients with initial peak oxygen consumption > 10 mL/kg per minute had a 2-year event-free rate of 72% compared with 48% for those with < 10 mL/kg per minute and 32% for those unable to exercise at referral. Demonstration of a 30% decrease in mortality with a controlled trial of new therapy in patients with ejection fraction < or = 25% would require 600 patients with class III symptoms or almost 300 patients with class IV symptoms unless another criterion were added. CONCLUSIONS Ambulatory populations with high predicted event rates can be identified at initial evaluation, when hemodynamic criteria may be less useful than ventricular dimension, serum sodium, and ability to exercise. The use of outcome data from previous eras may lead to overestimation of benefits from newer therapies and underestimation of the sample size required in a prospective trials.

Temporal Trends in Treatment and Outcomes for Advanced Heart Failure with Reduced Ejection Fraction from 1993-2010: Findings from a University Referral Center

Background—Randomized trials have demonstrated the efficacy of several new therapies for heart failure (HF) with reduced ejection fraction over the preceding 2 decades. This study investigates whether these therapeutic advances have translated into improvement in outcomes for patients with advanced HF referred to a heart transplant center. Methods and Results—Patients with HF (n=2507) referred to a single university center were analyzed in three 6-year eras during which medical and device therapies were evolving: 1993 to 1998 (era 1), 1999 to 2004 (era 2), and 2005 to 2010 (era 3). Impaired hemodynamics and comorbidities were more frequent at time of referral in later eras, whereas other HF severity parameters where similar or improved. Successive eras had greater usage of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, &bgr;-blockers, aldosterone antagonists, implantable cardioverter defibrillators, and cardiac resynchronization therapy, consistent with evolving evidence and guideline recommendations over the study period. All-cause mortality and sudden death were significantly lower in era 2 and 3 compared with era 1. After multivariable risk adjustment, era 3 had significantly decreased 2- and 3-year all-cause mortality risk and significantly decreased 1- and 3-year sudden death risk compared with era 1. However, progressive HF death and the combined outcome of mortality/urgent transplant/ventricular assist device were modestly increased in the latter eras. Conclusions—Over the past 2 decades, patients with advanced HF referred to and managed at a tertiary university referral center have benefited from advances in HF medications and devices, as evidenced by improvements in overall survival and sudden death risk.

Team-Based Care for Outpatients with Heart Failure

Management of heart failure requires a multidisciplinary team-based approach that includes coordination of numerous team members to ensure guideline-directed optimization of medical therapy, frequent and regular assessment of volume status, frequent education, use of cardiac rehabilitation, continued assessment for the use of advanced therapies, and advance care planning. All of these are important aspects of the management of this complex condition.

Outcomes of Biventricular Mechanical Support Patients Discharged to Home to Await Heart Transplantation

Background:The use of left ventricular assist devices has grown rapidly in recent years for patients with end-stage heart failure. A significant proportion of patients require both left- and right-sided support with biventricular assist devices (BiVADs) as a bridge to transplantation. Traditionally, these patients have waited in the hospital until they receive a transplant. Purpose:The aim of this study was to characterize the clinical course of BiVAD patients discharged to home to await heart transplantation. Methods:Between November 2009 and July 2011, 24 adult patients underwent Thoratec paracorporeal BiVAD placement at the University of California Los Angeles, all with an Interagency Registry for Mechanically Assisted Circulatory Support score 1 or 2. The disposition, complications, and rehospitalizations of these subjects were retrospectively reviewed. Results:Fourteen of the 24 patients were successfully discharged to home, with a mean time of 60 ± 27 days from BiVAD implantation to discharge. Ninety-three percent (13/14) of the patients sent home went on to be transplanted. Eleven of the 14 (79%) came in from home to receive their transplant. The mean time from BiVAD implantation to transplantation was 100 ± 65 days. Of the 14 patients discharged to home, there were 18 readmissions in 8 patients. Conclusion:In this small single-center review, we found that complex medical patients with BiVADs can be discharged to home and can await a heart transplant from home under the close management of multidisciplinary acute care and outpatient teams.

Evaluation of the SIPAT instrument to assess psychosocial risk in heart transplant candidates: A retrospective single center study

Objectives We evaluated the reliability of the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) in heart transplant (HT) recipients and explored its usefulness in predicting post‐transplant outcomes. Background Pre‐transplant psychosocial and behavioral risk is associated with post‐transplant clinical outcomes. SIPAT is a risk assessment tool created for pre‐transplant psychosocial evaluation. Methods Via retrospective chart review, three examiners applied the SIPAT to 51 adult HT recipients. Examiners blinded to SIPAT scores extracted data and interviewed clinicians for one‐year post‐transplant outcomes. Analysis included Intra‐class correlation coefficient (ICC), Pearsons correlation coefficient and Chi‐square. Results SIPAT demonstrated strong inter‐rater reliability (ICC = 0.89, 95% CI = 0.76–0.96). Compared to those with SIPAT ratings of “Excellent/Good”, the “Minimally Acceptable Candidate/High Risk” group was more likely to miss clinic visits (p = 0.004). Conclusions The SIPAT tool had strong IRR. Less favorable SIPAT ratings were associated with nonadherence to clinic visits. Further study is warranted to determine association of SIPAT ratings to clinical outcomes.

Temporal Trends in Treatment and Outcomes for Advanced Heart Failure With Reduced Ejection Fraction From 1993–2010Clinical Perspective

Background—Randomized trials have demonstrated the efficacy of several new therapies for heart failure (HF) with reduced ejection fraction over the preceding 2 decades. This study investigates whether these therapeutic advances have translated into improvement in outcomes for patients with advanced HF referred to a heart transplant center. Methods and Results—Patients with HF (n=2507) referred to a single university center were analyzed in three 6-year eras during which medical and device therapies were evolving: 1993 to 1998 (era 1), 1999 to 2004 (era 2), and 2005 to 2010 (era 3). Impaired hemodynamics and comorbidities were more frequent at time of referral in later eras, whereas other HF severity parameters where similar or improved. Successive eras had greater usage of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, &bgr;-blockers, aldosterone antagonists, implantable cardioverter defibrillators, and cardiac resynchronization therapy, consistent with evolving evidence and guideline recommendations over the study period. All-cause mortality and sudden death were significantly lower in era 2 and 3 compared with era 1. After multivariable risk adjustment, era 3 had significantly decreased 2- and 3-year all-cause mortality risk and significantly decreased 1- and 3-year sudden death risk compared with era 1. However, progressive HF death and the combined outcome of mortality/urgent transplant/ventricular assist device were modestly increased in the latter eras. Conclusions—Over the past 2 decades, patients with advanced HF referred to and managed at a tertiary university referral center have benefited from advances in HF medications and devices, as evidenced by improvements in overall survival and sudden death risk.

Temporal Trends in Treatment and Outcomes for Advanced Heart Failure With Reduced Ejection Fraction From 1993–2010Clinical Perspective: Findings From a University Referral Center

Background—Randomized trials have demonstrated the efficacy of several new therapies for heart failure (HF) with reduced ejection fraction over the preceding 2 decades. This study investigates whether these therapeutic advances have translated into improvement in outcomes for patients with advanced HF referred to a heart transplant center. Methods and Results—Patients with HF (n=2507) referred to a single university center were analyzed in three 6-year eras during which medical and device therapies were evolving: 1993 to 1998 (era 1), 1999 to 2004 (era 2), and 2005 to 2010 (era 3). Impaired hemodynamics and comorbidities were more frequent at time of referral in later eras, whereas other HF severity parameters where similar or improved. Successive eras had greater usage of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, &bgr;-blockers, aldosterone antagonists, implantable cardioverter defibrillators, and cardiac resynchronization therapy, consistent with evolving evidence and guideline recommendations over the study period. All-cause mortality and sudden death were significantly lower in era 2 and 3 compared with era 1. After multivariable risk adjustment, era 3 had significantly decreased 2- and 3-year all-cause mortality risk and significantly decreased 1- and 3-year sudden death risk compared with era 1. However, progressive HF death and the combined outcome of mortality/urgent transplant/ventricular assist device were modestly increased in the latter eras. Conclusions—Over the past 2 decades, patients with advanced HF referred to and managed at a tertiary university referral center have benefited from advances in HF medications and devices, as evidenced by improvements in overall survival and sudden death risk.