Shelley R. Hankins

Serum 25-Hydroxyvitamin D Concentration and Mortality from Heart Failure and Cardiovascular Disease, and Premature Mortality from All-Cause in United States Adults

We aimed to examine associations between serum 25-hydroxyvitamin D (25[OH]D) concentration and mortality from heart failure (HF) and cardiovascular disease (CVD) and premature death from all causes using data from the Third National Health and Nutrition Examination Survey, which included 13,131 participants (6,130 men, 7,001 women) ≥35 years old at baseline (1988 to 1994) and followed through December 2000. Premature death was defined all-cause death at <75 years of age. Results indicated that during an average 8-year follow-up, there were 3,266 deaths (24.9%) including 101 deaths from HF, 1,451 from CVD, and 1,066 premature all-cause deaths. Among HF deaths, 37% of decedents had serum 25(OH)D levels <20 ng/ml, whereas only 26% of those with non-HF deaths had such levels (p <0.001). Multivariate-adjusted Cox model indicated that subjects with serum 25(OH)D levels <20 ng/ml had 2.06 times higher risk (95% confidence interval 1.01 to 4.25) of HF death than those with serum 25(OH)D levels ≥30 ng/ml (p <0.001). In addition, hazard ratios (95% confidence intervals) for premature death from all causes were 1.40 (1.17 to 1.68) in subjects with serum 25(OH)D levels <20 ng/ml and 1.11 (0.93 to 1.33) in those with serum 25(OH)D levels of 20 to 29 ng/ml compared to those with serum 25(OH)D levels ≥30 ng/ml (p <0.001, test for trend). In conclusion, adults with inadequate serum 25(OH)D levels have significantly higher risk of death from HF and all CVDs and all-cause premature death.

Morbidity and mortality of UNOS status 1B cardiac transplant candidates at home

BACKGROUND On January 20, 1999, UNOS listing regulations changed, allowing stable patients on inotropic support (Status IB) to be discharged home until cardiac transplant. The outcome, morbidity and cost savings of this new strategy has not been evaluated. METHODS From 1/20/99 through 1/1/01, 155 patients were classified as UNOS Status 1B at our institution; 64 patients were never discharged and 91 were discharged home. Criteria for discharge were hemodynamic stability on low-dose, single-agent parenteral inotropic infusion, defined as dobutamine at a dose <7.5 microg/kg/min or milrinone <0.5 microg/kg/min. Data on re-admissions were collected prospectively. The frequency of complex ventricular arrhythmias was evaluated in a sub-group discharged with external or internal cardiodefibrillators (n = 38). RESULTS Total Status I time to transplant for the 91 discharged patients was 139 +/- 91 days, with 87 +/- 67 days spent at home. Inpatient time to transplant was still high, with a mean of 51 +/- 45 days. The in-hospital time was comparable to that of the 64 patients who were never discharged (51 +/- 41 days). Fifty-nine percent of discharged patients were re-admitted, with 37% of patients requiring more than 1 admission. Sixty-six percent of admissions were for worsening heart failure (CHF), and 34% for infection or occlusion of the indwelling intravenous line. No significant arrhythmic events were recorded in the 38 patients who had internal or external cardiodefibrillators. Two patients died suddenly at home. One patient had declined to wear the external cardiodefibrillator. The other patient was not wearing the defibrillator at the time of the event, and in 634 hours of previous monitoring he had had no events. CONCLUSIONS In UNOS Status 1B patients awaiting cardiac transplant on home inotropic therapy, mortality remains low but the re-admission rate was high. There appeared to be a low incidence of complex ventricular arrhythmias.

Subcutaneous Implantable Cardioverter-Defibrillator Implantation in a Patient with a Left Ventricular Assist Device Already in Place

A 56-year-old man with ischemic cardiomyopathy, a biventricular implantable cardioverter-defibrillator (ICD), and a left ventricular assist device (LVAD) developed a pocket hematoma and infection after an ICD generator change. The biventricular ICD was extracted, and the patient was given a full course of antibiotics. Because he had no indications for bradycardia pacing or biventricular pacing, he was implanted with a subcutaneous ICD under full anticoagulation. There was no interference in sensing or shock delivery from the ICD. The LVAD readings were unchanged during and after the procedure. The patient had an uneventful postoperative course, and both devices were functioning normally. To our knowledge, this is the first reported case of the implantation of a subcutaneous ICD in the presence of an LVAD. This report illustrates that both devices can be implanted successfully in the same patient. In addition, the subcutaneous ICD minimizes the risk of bloodstream infections, which can be fatal in patients who have life-supporting devices such as an LVAD.

Dose-dependent blockade of the angiotensin II type 1 receptor with losartan in normal volunteers

&NA; Losartan, an angiotensin II type 1 receptor (AT1) antagonist, was developed as a more specific alternative to angiotensin‐converting enzyme (ACE) inhibitors. At a daily dose of 50 mg, losartan is currently evaluated in large outcome trials involving patients with hypertension and postmyocardial infarction. The current study evaluated the level and duration of blockade of a pressor response to angiotensin II by 50 and 150 mg of losartan, compared with 32 mg of candesartan. Eight normotensive volunteers were randomly assigned to a single dose of losartan 50 or 150 mg, candesartan 32 mg, or placebo. Subjects were re‐randomized after a 2‐week washout period to complete all four study arms. Radial artery systolic pressure response to exogenous angiotensin II was measured at 2, 6, 12, and 24 h after administration of drug. Losartan 50 mg reduced the pressure response to exogenous angiotensin II significantly only at 6 h. In contrast, candesartan and losartan 150 mg produced a greater reduction in the pressure response to angiotensin II throughout the 24‐h period. This suppression was not paralleled by a reduction in resting systemic arterial pressure. Higher doses than 50 mg of losartan might be evaluated to elicit optimal clinical effects.

Continuous flow rotary left ventricular assist device: mechanical circulatory support 2.0.

Cardiac transplantation provides definitive management of severe heart failure in selected patients who have exhausted all other options. The results of transplantation have improved steadily as a result of improved immunosuppressive strategies, and advances in the therapy of post-transplant

Adjunctive Therapy and Management of the Transition of Care in Patients with Heart Failure

Heart failure is a costly and difficult disease to treat. However, new metrics make it an imperative to keep these patients out of the hospital. Implementing and maintaining patients on successful treatment plans is difficult. A multitude of factors make transitioning care to the outpatient setting difficult. A careful and well-orchestrated team of cardiologists, general practitioners, nurses, and ancillary support staff can make an important difference to patient care. A strong body of literature supports the use of pharmacologic therapy, and evidence-based therapies can improve mortality and quality of life, and reduce hospital admissions. Adjunctive therapies can be equally important.

Evaluation of a Heart Transplant Candidate

Purpose of ReviewHeart transplantation is the best option for irreversible and critically advanced heart failure. However, limited donor pool, the risk of rejection, infection, and right ventricular dysfunction in short-term post-transplant period, as well as, the development of coronary allograft vasculopathy and malignancy in the long-term post-transplant period limits the utility of heart transplantation for all comers with advanced heart failure. Therefore, selection of appropriate candidates is very important for the best short and long-term prognosis. In this article, we discuss the principles of selection of candidates and compare to the recently updated International Society for Heart and Lung Transplantation (ISHLT) listing criteria with the goal of updating current clinical practice.Recent FindingsWe found that while most of the recommendations in the new listing criteria are continuous with the previous criteria, updated recommendations are made on the risk stratification models in choosing transplantation candidates. Recommendation on hepatic dysfunction is not directly included in the updated ISHLT listing criteria; however, adoption of the Model for End-stage Liver Disease (MELD) score and modified MELD scores in the evaluation of risk are suggested in recent studies.SummaryIn conclusion, evaluation of patient selection for heart transplantation should be comprehensive and individualized with respect to indications and the risk of comorbidities of candidates. With the advancement of mechanical circulatory support (MCS), the selection of heart transplantation candidate is continuously evolving and widened. MCS as bridge to candidacy should be considered when the candidate has potentially reversible risk factors for transplantation.

Mechanical Circulatory Support in the Treatment of Advanced Heart Failure

According to the Centers for Disease Control, heart failure (HF) remains a pervasive condition with high morbidity and mortality, affecting 5.8 million people in the United States and 23 million worldwide. For patients with refractory end‐stage HF, heart transplantation is the “gold standard” for definitive treatment. However, the demand for heart transplantation has consistently exceeded the availability of donor hearts, with approximately 2331 orthotopic heart transplantations performed in the United States in 2015 despite an estimated 100 000 to 250 000 patients with New York Heart Association class IIIB or IV symptoms that are refractory to medical treatment, making such patients potential transplant candidates. As such, the need for mechanical circulatory support (MCS) to treat patients with end‐stage HF has become paramount. In this review, we focus on the history, advancements, and current use of durable MCS device therapy in the treatment of advanced heart failure.

Listing and treatment of status 1 patients

Although therapies for heart disease continue to improve life expectancy, mortality remains high for those with end-stage heart disease despite aggressive medical treatment. The goal of transplantation is to improve survival in this difficult group of patients. Recent data show 1-, 3-, and 5-year posttransplant survival rates at 85.5%, 76.9%, and 69.6%, respectively. During the past decade, efforts have been made to expand the donor pool by increasing public awareness regarding organ donation and expanding criteria for donor acceptance. Transplant centers have become more restrictive in transplant candidate selection during this period, and the number of new registrations has decreased in the past 5 years. Despite these efforts, the supply–demand mismatch persists. As the number of those awaiting transplantation grows, so too have the number of transplants performed on an urgent basis. Three quarters of the organs allocated in 1988 to 1999 went to high-priority patients, whereas about half the transplants performed in 1995 were considered urgent. Despite this shift in patient acuity, outcomes have remained stable during the past decade. This stability is probably the result of the growing expertise in caring for these critically ill patients and to improved immunosuppression.

Angiotensin-Converting Enzyme Inhibitors for Cardiac Allograft Vasculopathy After Heart Transplantation∗

SEE PAGE 2832 O utcomes of cardiac transplantation have been improved with immunosuppressive therapies that effectively reduce the risk of rejection and with prophylaxis against opportunistic infections. With the current management leading to decreased likelihood of hyperacute and acute rejections, efforts have been focused on improving long-term survival by targeting post-transplant complications associated with chronic rejection. Cardiac allograft vasculopathy (CAV) has been 1 of the main causes of mortality for heart transplant recipients (1). The CAV progression has been traditionally managed with mechanistic target of rapamycin inhibitors, such as sirolimus and everolimus. Though mechanistic target of rapamycin inhibitors have been successful in ameliorating or preventing CAV, they frequently cause many significant side effects, like pancytopenia, wound healing issues, renal dysfunction and hyperlipidemia (2). This has limited their widespread use. Statins have been demonstrated to reduce the incidence of CAV (3). Today, post-transplant patients are commonly placed drugs such as statins for potential CAV improvement as well angiotensin-converting enzyme inhibitors (ACEIs) for their most common indications, like hypertension (3,4). Patients with heart failure often take ACEIs prior to heart transplantation. Not only do ACEIs decrease mortality in patients with heart failure, but they