Sandip Zalawadiya

Early outcomes using hepatitis C–positive donors for cardiac transplantation in the era of effective direct-acting anti-viral therapies

BACKGROUND Given the shortage of suitable donor hearts for cardiac transplantation, and the favorable safety and efficacy of current agents used to treat hepatitis C virus (HCV), our institution recently piloted transplantation of select patients using HCV-positive donors. METHODS Between September 2016 and March 2017, 12 HCV-naive patients and 1 patient with a history of treated HCV underwent heart transplantation (HT) using hearts from HCV-positive donors after informed consent. Patients who acquired HCV were referred to hepatology and treated with direct-acting anti-viral therapies (DAAs). Data collection and analysis were performed with institutional review board approval. RESULTS At the time of HT, mean age of recipients was 53 ± 10 years, and 8 patients (61.5%) were on left ventricular assist device support. After consent to consider an HCV-positive heart, mean time to HT was 11 ± 12 days. Nine of 13 patients (69%) developed HCV viremia after transplant, including 8 who completed DAA treatment and demonstrated cure, as defined by a sustained virologic response 12 weeks after treatment. One patient died during Week 7 of his treatment due to pulmonary embolism. DAAs were well tolerated in all treated patients. CONCLUSIONS In the era of highly effective DAAs, the use of HCV-positive donors represents a potential approach to safely expand the donor pool. Additional follow-up is needed to elucidate long-term outcomes.

Extracorporeal membrane oxygenation support and post-heart transplant outcomes among United States adults

BACKGROUND Patients supported with extracorporeal membrane oxygenation (ECMO) are given priority listing status for heart transplant (HT). Data on post-HT outcomes for adults with ECMO support at the time of HT are limited. METHODS We analyzed data from the United Network for Organ Registry (UNOS) registry for 157 ECMO-supported adults (age ≥ 18 years) undergoing HT after January 1, 2000. Data at the time of HT were examined for their association with post-transplant mortality using multivariable Cox proportional hazard analyses. RESULTS Patients (69.4% males; mean age, 46.0 ± 15.6 years; 15.9% African Americans) were monitored for median of 0.55 years (interquartile range, 0.04-4.5). Seventy patients (44.6%) died during follow-up (survival at 1 year was 57.8%), of which 43 (61.4%) died within 30 days post-HT. For patients surviving the first 30 days after transplant, long-term survival was acceptable (82.3% at 1 year and 76.2% at 5 years). Prevalence of immediate post-HT complications, such as stroke and need for dialysis, were 10.1% and 28.1%, respectively. Post-HT survival did not differ between those who received an allograft before and after January 1, 2009 (univariate hazard ratio, 0.84; 95% confidence interval, 0.51-1.38; p = 0.48). Among the predictors identified for 30-day and long-term mortality were recipient history of renal insufficiency (RI; defined as estimated glomerular filtration rate < 45 ml/min/1.73 m2 or dialysis) and mechanical ventilation (MV; interaction p < 0.05); those with both MV and RI had significantly poorer post-transplant survival (29.4% and 12.5% for 30-day and 1-year survival, respectively) compared with those without (78.7% and 71.4% for 30-day and 1-year survival, respectively). CONCLUSIONS Post-HT mortality did not change for ECMO-supported adults in the contemporary era, and those with RI and MV had significantly poorer post-transplant survival. A critical review of priority listing status for ECMO-supported patients is warranted for optimal allocation and outcomes of cardiac allografts.

Vitamin D and Heart Failure

PurposeVitamin D is principally known for its role in calcium homeostasis, but preclinical studies implicate multiple pathways through which vitamin D may affect cardiovascular function and influence risk for heart failure. Many adults with cardiovascular disease have low vitamin D status, making it a potential therapeutic target. We review the rationale and potential role of vitamin D supplementation in the prevention and treatment of chronic heart failure.Recent Findings.Substantial observational evidence has associated low vitamin D status with the risk of heart failure, ventricular remodeling, and clinical outcomes in heart failure, including mortality. However, trials assessing the influence of vitamin D supplementation on surrogate markers and clinical outcomes in heart failure have generally been small and inconclusive.SummaryThere are insufficient data to recommend routine assessment or supplementation of vitamin D for the prevention or treatment of chronic heart failure. Prospective trials powered for clinical outcomes are warranted.

Mechanical circulatory support and simultaneous heart-kidney transplantation: An outcome analysis

BACKGROUND Single-donor simultaneous heart-kidney transplantation (SHKT) can significantly improve the survival of those with advanced heart failure and advanced renal insufficiency. Data on pre-transplant use of mechanical circulatory support (MCS) devices and outcomes after SHKT are limited and conflicting. METHODS Using the United Network for Organ Sharing registry data, we evaluated 749 adults undergoing SHKT after January 1, 2000. Patients were categorized into the following groups according to their type of pre-transplant MCS device: none (n = 568), pulsatile-flow left (n = 28), continuous-flow left (n = 68), temporary (n = 12), biventricular (n = 19), total artificial heart (n = 20), and unknown (n = 34). Regression analyses were performed to assess the association between types of MCS and post-transplant outcomes. RESULTS Pre-transplant MCS was not associated with in-hospital mortality (univariate odds ratio [OR], 1.57; 95% confidence interval [CI], 0.82-2.97; p = 0.170) or post-discharge mortality (univariate hazard ratio, 0.92; 95% CI, 0.58-1.47; p = 0.733). Patients supported with pre-transplant temporary MCS devices were more likely to suffer from serious complications (composite of cardiac or non-cardiac surgeries, stroke, any drug-treated infection, and permanent pacemaker; multivariable adjusted OR, 10.0; 95% CI, 2.77-36.0; p < 0.001) after SHKT. Pre-transplant MCS did not increase risk of post-transplant dialysis (multivariable adjusted OR, 1.19; 95% CI, 0.81-1.75; p = 0.375) or cardiac rejection (univariate OR, 0.71; 95% CI, 0.34-1.51; p = 0.382), and did not prolong the length of hospital stay (≥ 4 weeks; multivariable adjusted OR, 1.05; 95% CI, 0.69-1.59; p = 0.832). Post-transplant dialysis status was a major determinant of adverse in-hospital (multivariable adjusted OR, 6.17; 95% CI, 3.14-12.1; p < 0.001) and post-discharge (multivariable adjusted hazard ratio, 1.56; 95% CI, 1.02-2.39; p = 0.041) mortality after SHKT. CONCLUSIONS In the current transplant era, survival after SHKT in patients with pre-transplant MCS was equivalent to that of conventional SHKT. Pre-transplant dialysis, and not MCS status, determined the need for post-SHKT dialysis, which in-turn was a major risk factor for in-hospital and long-term mortality.

Data on coronary artery calcium score performance and cardiovascular risk reclassification across gender and ethnicities

The current guidelines recommend the new risk score, Atherosclerotic Cardiovascular Disease score (ASCVD), to assess an individual׳s risk of future cardiovascular disease (CVD) events. No data exist on the predictive utility of ASCVD score with the incremental value of coronary artery calcium scoring (CACS) across ethnicities and gender. Multi-Ethnic Study of Atherosclerosis (MESA) is a population based study (n=6814) of White (38%), Black (28%), Chinese (22%) and Hispanic (12%) subjects, aged 45–84 years, free from clinical cardiovascular disease. We performed a post-hoc analysis of 6742 participants (mean age 62, 53% female) from the MESA cohort. We evaluated the predictive accuracy for the ASCVD score for each participant in accord with the American College of Cardiology/American Heart Association guidelines using pooled cohort equations. Similar to the publication by Fudim et al. “The Metabolic Syndrome, Coronary Artery Calcium Score and Cardiovascular Risk Reclassification” [1] the analytic properties of models incorporating the ASCVD score with and without CACS were compared for cardiovascular disease CVD prediction. Here the analysis focused on ASCVD score (with and without CACS) performance across gender and ethnicities.

Rapid Diagnosis of Cardiac Tamponade Using Pulsatility Index Variability in a Patient With a HeartWare Ventricular Assist Device

A 59-year-old man with nonischemic cardiomyopathy, advanced heart failure, and group 2 pulmonary hypertension underwent HeartWare left ventricular assist device (LVAD) implantation as bridge to transplantation. Off-pump LVAD implantation was performed via minimally invasive left thoracotomy and upper hemisternotomy with an estimated blood loss of 200 mL. Postoperative VAD settings were as follows: speed, 2600 rpm; power, 4 W; flow, 5.5 to 5.7 L/min; and pulsatility index (PI), 4. Aspirin 325 mg daily and warfarin were begun on postoperative day 1. Over the course of the next few days, he was extubated and optimized hemodynamically with continued inotropic support (milrinone), and a therapeutic international normalized ratio (2–3) was achieved. Before his transfer out of the intensive care unit, he underwent a transthoracic echocardiogram, …

Correction to: Vitamin D and Heart Failure

The original version of this article, published in Current Heart Failure Reports, Volume 14, Issue 5, October 2017, erroneously cited an author’s name as Marshall Brinkley, D” when it should be “Brinkley, DM.”

GENDER, CORONARY ARTERY CALCIUM SCORE AND CARDIOVASCULAR RISK RECLASSIFICATION

Recent guidelines propose the use of the Atherosclerotic Cardiovascular Disease (ASCVD) score to assess an individual’s risk of future cardiovascular disease (CVD) events. Limited data exist evaluating the role of coronary artery calcium score (CACS) as an adjunct to the ASCVD score and general CV

Mechanical bridge to long-term device implant: the necessary step for better outcomes.

Cardiogenic shock (CS) has profound impact on shortand long-term mortality and morbidities.1–3 However, recent advancements in revascularization strategies and availability of newer generation shortand long-term mechanical circulatory support devices (MCSD) have significantly improved outcomes in patients with CS.2,3 The significance lies in particular with the short-term MCSD as they not only provide successful hemodynamic support but also serve as a “bridge to decision” (BTD) for heart transplantation and durable MCSD or “bridge to bridge” (BTB) for durable MCSD. Among myriads of temporary short-term devices available in the market today, particular emphasis should be placed upon certain technical, clinical, and economic characteristics of these VADs when choosing one (Table 1). Impella 5.0 (Abiomed, Danvers, MA) is one of the short-term MCSD, which is approved in the United States since 2009 for circulatory support up to 6 hours and have CE mark approval in Europe for up to 10 days duration. It is a microaxial, catheter-based MCSD which is inserted in a retrograde fashion via peripheral surgical vascular access. Technical ease of utilization and profile of hemodynamic support makes it an attractive short-term MCSD option.4 With its ability to be inserted in axillary artery, it raises the field of short-term MCSD to a higher level. Besides providing adequate hemodynamic support and thereby supporting the end-organ function and allowing adequate time to assess the candidacy for heart transplant or durable MCSD implantation, it also allows for early ambulation and rehabilitation; thereby, helping to optimize clinical condition of CS patients before a major cardiac surgery. At present, the clinical experience with Impella 5.0 implantation via axillary approach is limited and, therefore, study by Doersch et al.5 certainly adds to the growing body of literature.6–10 In their report of 15 patients supported via axillary Impella 5.0 (~94% of the patients being in Interagency Registry of Mechanically Assisted Circulatory Support class I), they were successful in reducing their 30 day and discharge mortality to 27% and 33%, respectively. In addition, Impella 5.0 use was successful as BTB for durable MCSD implantation in 20% of the patients (three out of 15 HeartMate II implantation) and bridging to recovery for the remaining patients (40%, six out of 15) at the time of discharge. These findings are comparable, if not better than that of published reports on other temporary MCSDs.11–14 Adverse shortand long-term association of prolonged bed-rest among hospitalized patients, especially those in intensive care units (ICU), have been well demonstrated.15 Physical therapy and early progressive ambulation among ICU patients is not only feasible,16,17 but also considered a standard of care now, especially after cardiac surgery.18 From the commercially available temporary MCSDs, intraaortic balloon pump (IABP; axillary approach), Centrimag and Impella (axillary approach) are the only devices having potential to allow for early ambulation. Prior reports with both axillary IABP19 and Centrimag11,20 support have shown that they can be successfully used as bridge to recovery, transplantation or durable MCSD implantation and can allow early ambulation. However, suboptimal hemodynamic support offered by IABP4,21 and the need for sternotomy approach with Centrimag implantation20 can potentially be the limitation of these two devices. On the contrary, axillary Impella 5.0 provides better hemodynamic support and does not need a sternotomy for implantation; thereby, making it an attractive option for temporary MCSD support. Doersch et al.5 were able to demonstrate high success rate with axillary Impella 5.0 for early ambulation in majority of the patients along improved hemodynamics and stabilization of the end-organ function. In addition, they observed minimal device-related complications; notably none had access site bleeding, hematoma or infection and thromboembolism, and only one patient had mild aortic regurgitation and another had device failure. Hemolysis related to the device use requiring blood transfusions are common with Impella use.22 Although no information was available for blood transfusions requirement in the study by Doersch et al.,5 a nonsignificant drop in hemoglobin and hematocrit levels was observed. Hemolysis requiring blood transfusions can be an important limitation of Impella use, especially for those to be considered for heart transplantation as number of blood transfusions can potentially increase the risk of sensitization and graft dysfunction/loss.23 Although the successful experience of Impella 5.05 is encouraging, an important limitation of sample size needs to be taken into account while reviewing their findings. In aggregate, study done by Doersch et al.5 is an encouraging step toward emphasizing the importance of early ambulation in the management of CS patients. It further opens up the field for questions; especially, the direct comparison between temporary MCSDs capable of providing adequate hemodynamic support along with allowing for early ambulation in patients with CS before their cardiac surgery as BTD or BTB. Mechanical Bridge to Long-Term Device Implant: The Necessary Step for Better Outcomes