Sandhya Murthy

Cardiac Recovery During Mechanical Assist Device Support

It is estimated that approximately 100,000 patients in the United States with advanced heart failure might benefit from cardiac transplantation, while donors are available for only 2000 recipients each year. Left ventricular assist devices (LVADs) are used both for bridge to transplantation and for long term support in patients ineligible for transplant. Both cardiac transplantation and long term LVAD therapy are limited by the complications of immunosuppression and device malfunction. Currently, a major focus of investigation in advanced heart failure is the temporary use of LVADs as a bridge to recovery of the native heart. While end-stage heart failure was once thought to be irreversible, research now suggests that LVAD support may lead to both cellular and functional recovery. Ultimately, patients with advanced cardiac disease might be managed with temporary mechanical support combined with pharmacological and cellular therapies, in place of cardiac transplantation or long term LVAD support. In this paper we review the evidence demonstrating the impact of LVAD support on the pathophysiology of end stage heart failure. Furthermore, we outline the clinical evidence for cardiac recovery seen in LVAD patients. Finally, we describe techniques to measure cardiac function during LVAD support and the criteria that have been suggested to select patients for device explantation for recovery.

Heart failure in women

Heart failure (HF) has steadily increased in prevalence and affects both males and females equally. Despite this, there has been a significant underrepresentation of women in large scale HF trials. This disparity has lead to a deficit in understanding important gender‐based differences in pathophysiology, diagnosis and treatment strategies.

Management of End-Stage Heart Failure

The prevalence of heart failure (HF) is increasing and morbidity and mortality remain high. There is a clear need for palliative care for the growing population of chronically ill patients with HF. Because HF-specific therapy modifies disease and palliates symptoms, recommended treatments for chronic and acute decompensated HF are reviewed. This article discusses symptom burden in advanced HF and specific considerations for patients with HF regarding advance care planning and symptom-directed therapy. Options for care at the end of life, including hospice, chronic inotropic support, and deactivation of an internal cardiac defibrillator, are also discussed.

Cardiac transplantation from non-viremic hepatitis C donors

BACKGROUND Hepatitis C (HCV) donors are rarely used for cardiac transplantation due to historically poor outcomes. In 2015, nucleic acid testing (NAT) for viral load was added to the routine work-up of organ donors, allowing for the distinction between subjects who remain viremic (HCV Ab+/NAT+) and those who have cleared HCV and are no longer viremic (HCV Ab+/NAT-). The American Society of Transplantation recently recommended that HCV Ab+/NAT- donors be considered non-infectious and safe for transplantation. We present our initial experience with such donors. METHODS All patients were counseled regarding donor HCV antibody (Ab) and NAT. Transplant recipients were tested post-transplant at 1 week and at 1, 3, and 6 months for HCV seropositivity and viremia. We also analyzed the UNOS database to determine the potential impact of widespread acceptance of HCV Ab+/NAT- organs. RESULTS Fourteen HCV Ab‒ subjects received hearts from HCV Ab+/NAT- donors in 2017. Over a median follow-up of 256 (192 to 377) days, 3 patients developed a reactive HCV Ab, yet none had a detectable HCV viral load during prospective monitoring at any time. Analysis of the UNOS database for the calendar year 2016 revealed that only 7 (3%) of 220 HCV Ab+/NAT- donors were accepted for heart transplantation. CONCLUSIONS We have demonstrated the feasibility of utilizing HCV Ab+/NAT- donors for cardiac transplantation without recipient infection. A small percentage of recipients developed HCV Ab without evidence of viremia, possibly consistent with a biological false reactive test, as has been seen in other settings. Large-scale validation of our data may have a significant impact on transplantation rates.

HIGH CENTER VOLUME IS ASSOCIATED WITH LOWER IN-HOSPITAL MORTALITY IN HEART FAILURE PATIENTS: A NEW YORK STATE WIDE ANALYSIS OF 300,000 ADMISSIONS

Center volume is a determinant of outcomes in patients requiring complex medical treatments. We evaluated the effect of center volume on in-hospital mortality in patients with a primary discharge diagnosis of heart failure (HF). A retrospective analysis of adult patients with a primary discharge

Severity of Hemolysis Is Associated with Death and Ischemic Stroke during Veno-Arterial Extracorporeal Membrane Support

Purpose: Acquired Von Willebrand Factor (vWF) deficiency due to the loss of high molecular weight multimers (HMWM) has been well documented during CF LVAD support. It has been proposed that lowering pump speed in response to clinical gastrointestinal bleeding (GIB) may decrease shear stress allowing for the return of HMWMs. In-vivo data supporting this practice is lacking. Methods: Subjects at least 30 days post implantation of a Heart Mate (HM) II were prospectively recruited from the LVAD clinic. After confirming INR was > 2.0, pump speed was decreased to 8000 rpm and maintained for 6 hours. Blood samples obtained at baseline and 6 hours were compared for 2 measures of acquired vWF deficiency: 1) the ristocetin cofactor activity to vWF antigen ratio (Rco:Ag) and 2) gel electrophoresis for vWF multimer distribution. Results: Four patients agreed to participation. They were 57±15 years old, all were male and had been on HM II support for 401±199 days. All patients tolerated speed reduction without any adverse events. At baseline speed, HMWMs were reduced in all 4 patients. After 6 hours at 8000 rpm, there was no change in the HMWM profile (Figure 1). Similarly, the Rco:Ag ratio was reduced (nl > 0.65) in 3 of 4 patients at baseline and did not significantly change after speed reduction (0.56 → 0.56, 0.74 → 0.67, 0.58 → 0.65, 0.47 → 0.45; p = 0.437). Conclusion: Decreasing pump speed during HM II support does not lead to restoration of HMW Von Willebrand multimers. These findings suggest there may be no benefit to speed reduction in response to GIB. ( 662)