Mohamed Labedi

Pulsatility and the Risk of Nonsurgical Bleeding in Patients Supported With the Continuous-Flow Left Ventricular Assist Device HeartMate II

Background—Bleeding is an important cause of morbidity and mortality in patients with continuous-flow left ventricular assist devices (LVADs). Reduced pulsatility has been implicated as a contributing cause. The aim of this study was to assess the effects of different degrees of pulsatility on the incidence of nonsurgical bleeding. Methods and Results—The Utah Transplantation Affiliated Hospitals (U.T.A.H.) heart failure and transplant program databases were queried for patients with end-stage heart failure who required support with the continuous-flow LVAD HeartMate II (Thoratec Corp, Pleasanton, CA) between 2004 and 2012. Pulsatility was evaluated by means of the LVAD parameter pulsatility index (PI) and by the echocardiographic assessment of aortic valve opening during the first 3 months of LVAD support. PI was analyzed as a continuous variable and also stratified according to tertiles of all the PI measurements during the study period (low PI: <4.6, intermediate PI: 4.6–5.2, and high PI: >5.2). Major nonsurgical bleeding associated with a decrease in hemoglobin ≥2 g/dL (in the absence of hemolysis) was the primary end point. A total of 134 patients (median age of 60 [interquartile range: 49–68] years, 78% men) were included. Major bleeding occurred in 33 (25%) patients (70% gastrointestinal, 21% epistaxis, 3% genitourinary, and 6% intracranial). In multivariable analysis, PI examined either as a categorical variable, low versus high PI (hazard ratio, 4.06; 95% confidence interval, 1.35–12.21; P=0.04), or as a continuous variable (hazard ratio, 0.60; 95% confidence interval, 0.40–0.92; P=0.02) was associated with an increased risk of bleeding. Conclusions—Reduced pulsatility in patients supported with the continuous-flow LVAD HeartMate II is associated with an increased risk of nonsurgical bleeding, as evaluated by PI.

Prevalence and Impact of Chagas Disease Among Latin American Immigrants With Nonischemic Cardiomyopathy in Los Angeles, California

Background—Chagas disease is a well-known cause of cardiomyopathy in Latin America; however, 300 000 individuals are estimated to have Chagas disease in the United States. This study examined the prevalence and impact of Chagas cardiomyopathy (CCM) in a US population. We hypothesized that patients with CCM would have increased morbidity and mortality when compared with patients with non-CCM. Methods and Results—This is a single-center, prospective cohort study. Enrollment criteria were new diagnosis of nonischemic cardiomyopathy (left ventricular ejection fraction ⩽40%) and previous residence in Latin America for at least 12 months. Serological testing for Trypanosoma cruzi was performed at enrollment. The primary end point was all-cause mortality or heart transplantation. The secondary end point was heart failure–related hospitalization. A total of 135 patients were enrolled, with a median of 43 months of follow-up. Chagas disease was diagnosed in 25 (19%) patients. The primary end point occurred in 9 patients (36%) in the CCM group and in 11 patients (10%) in the non-CCM group (hazard ratio [HR], 4.46; 95% confidence interval, 1.8–10.8; P=0.001). The secondary end point occurred in 13 patients (52%) in the CCM group and in 35 patients (32%) in the non-CCM group (HR, 2.22; 95% confidence interval, 1.2–4.2; P=0.01). Conclusions—There is a high prevalence of Chagas disease among Latin American immigrants diagnosed with nonischemic cardiomyopathy in Los Angeles. Advanced CCM portends a poor prognosis and is associated with increased all-cause mortality/heart transplantation and heart failure–related hospitalization.

Abnormal Finding on a Screening Endomyocardial Biopsy

Each month, the American Journal of Transplantation will feature Images in Transplantation, a journal-based CME activity, chosen to educate participants on current developments in the science and imaging of transplantation. Participants can earn 1 AMA PRA Category 1 CreditTM per article at their own pace. This month’s feature article is titled: “Abnormal Finding on a Screening Endomyocardial Biopsy.” Accreditation and Designation Statement This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Blackwell Futura Media Services, the American Society of Transplant Surgeons and the American Society of Transplantation. Blackwell Futura Media Services is accredited by the ACCME to provide continuing medical education for physicians. Blackwell Futura Media Services designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should only claim credit commensurate with the extent of their participation in the activity. Statement of Need Amyloidosis is a relatively common disease, which presents specific diagnostic and therapeutic challenges. There often is a considerable delay between onset of symptoms and the correct diagnosis in patients with amyloidosis. There are newer approaches to amyloidosis treatment and knowledge of these treatments is in need of dissemination. This activity reviews key features of cardiac amyloidosis and provides physicians with the opportunity to update their knowledge in a succinct format. This activity is designed to improve competence (ability to apply knowledge to practice). Educational Objectives Upon completion of this educational activity, participants will be better able to: • Identify patients who may suffer from amyloidosis • Describe the common types of cardiac amyloidosis • Summarize the clinical and pathological features of amyloidosis • Recognize that amyloidosis can recur in transplanted organs Target Audience This activity has been designed to meet the educational needs of physicians and surgeons in the field of transplantation. Disclosures No commercial support has been accepted related to the development or publication of this activity. Blackwell Futura Media Services has reviewed all disclosures and resolved or managed all identified conflicts of interest, as applicable. The following authors, editors, and staff reported no relevant financial relationships with respect to this activity. Editor-in-Chief Allan D. Kirk, MD, PhD, FACS Editors Sandy Feng, MD, PhD Douglas W. Hanto, MD, PhD Authors Josef Stehlik, MD, Mohamed Labedi, MD, Dylan Miller, MD and Monica P. Revelo, MD ASTS Staff Mina Behari, Director of Education This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by the American Journal of Transplantation. The peer reviewers have no relevant financial relationships to disclose. The peer review process for the American Journal of Transplantation is blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review. Instructions on Receiving CME Credit This activity is designed to be completed within an hour. Physicians should claim only those credits that reflect the time actually spent in the activity. This activity will be available for CME credit for twelve months following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional twelve months. Follow these steps to participate, answer the questions and claim your CME credit: • Log on to www.amjtrans.com/cme • Read the target audience, educational objectives, and activity disclosures. • Read the article in print or online format. • Reflect on the article. • Access the CME Exam, and choose the best answer to each question. • Complete the required evaluation and print your CME certificate.

UTILITY OF AN ESOPHAGEAL SCREENING PROTOCOL IN PREVENTING ATRIO-ESOPHAGEAL FISTULA AFTER ATRIAL FIBRILLATION ABLATION

Background: Atrioesophageal fistula is a well-recognized complication of catheter ablation of atrial fibrillation (AF) with a reported incidence of 0.015-0.2%. Careful screening with Magnetic resonance imaging (MRI) and Esophagogastroduodenosopy (EGD) may help avoid this potentially lethal

ASSOCIATIONS BETWEEN CHA2DS2-VASC AND DEGREE OF ATRIAL FIBROSIS

The relationship between cardiac and atrial fibrosis, and atrial fibrillation (AF) is well established. The objective of this study is to evaluate the relationship between CHADS2-VASc score and LA fibrosis.nnA cross-sectional study of patients with LA fibrosis scores was performed. Participants

IMPACT OF INDIVIDUAL COMPONENTS OF THE CHA2DS2-VASC SCORE COMPARED WITH ATRIAL FIBRILLATION ON LEFT ATRIAL FIBROSIS PROGRESSION

Atrial fibrillation (AF) results in remodeling/fibrosis of the left atrium (LA). This relationship is modified by multiple factors. The objective of this study is to determine which factors have the strongest association with left atrial (LA) fibrosis using late gadolinium-enhancement cardiovascular

Atrial fibrosis progression in patients with Atrial Fibrillation

Methods Eighty-eight patients (58% male, mean age 60.4+/-14.7) with AF who underwent late gadolinium enhancement MRI (LGE-MRI) to assess the degree of atrial tissue fibrotic changes were included in this study. All patients underwent at least 2 or more LGE-MRI separated by more than 3 months of follow up. Progression of fibrosis was defined as an increase in fibrosis area by more than 5% (Figure 1). Demographic patient data as well as comorbidities and medications were collected from chart revisions.

Invasive treatment of atrial fibrillation.

Purpose of review The treatment of atrial fibrillation has experienced a significant evolution over the past two decades. Catheter-based ablation has become a first-line option in various guidelines. In this review, we highlight the recent multicenter ablation studies and the challenges facing this treatment modality. Recent findings Improved efficacy and safety of an invasive treatment of paroxysmal and persistent atrial fibrillation with catheter ablation. Summary Atrial fibrillation is a major health problem. Catheter ablation has become a standard of care in managing paroxysmal and persistent atrial fibrillation. This treatment modality, however, still faces major challenges, especially in patients presenting with persistent atrial fibrillation.