Abstract The purpose of this study is to examine the association of sarcopenia as measured by psoas muscle area and outcomes in patients undergoing LVAD implantation. We retrospectively examined 333 ...consecutive patients who underwent implantation of a HeartMate II LVAD at our institution between June 2008 and August 2013. Patients were included if they had a perioperative CT that spanned the L3-L4 vertebrae. Sarcopenia was defined as having lowest tertile psoas muscle area by gender. The primary endpoint was the composite of inpatient death or prolonged length of stay of >30 days. 100 patients met inclusion criteria. The psoas muscle area cut-off values for the lowest tertiles were 12.0 cm2 for males and 6.5 cm2 for females, resulting in n=32 (32%) sarcopenic. The primary outcome of inpatient death or prolonged length of stay occurred in 81% of patients in the sarcopenic vs 60% of the non-sarcopenic group (p=0.043). There was a trend toward prolonged length of stay in sarcopenic patients but no difference in overall mortality. This demonstrates that sarcopenia as measured by psoas muscle area is associated with increased composite length of stay and mortality following LVAD implantation and may serve as correlate for frailty.
Purpose of review
The revised United States heart organ allocation system was launched in October 2018. In this review, we summarize this United Network for Organ Sharing (UNOS) policy and describe ...intended and unintended consequences.
Recent findings
Although early studies published after the change suggested postheart transplant survival declined at 6 months and 1 year, recent publications with longer follow-up time have confirmed comparable posttransplant survival in adjusted models and several patient cohorts. Moreover, the new allocation decreased overall waitlist time from 112 to 39 days (
P
< 0.001). Mean ischemic time increased because of greater distances traveled to acquire donor hearts under broader sharing. Despite the intention to decrease exception requests by expanding the number of priority tiers to provide more granular risk stratification, ∼30% of patients remain waitlisted under exception status. Left-ventricular assist device (LVAD) implants are declining and the number of LVAD patients on the transplant list has decreased dramatically after the allocation system change.
Summary
As the next allocation system is developed, it is imperative to curtail the use of temporary mechanical support as a strategy solely for listing purposes, identify attributes that more clearly stratify the severity of illness, provide greater oversight of exception requests, and address concerns regarding patients with durable LVADs.
Purpose of Review
In recent decades, multiple left and right ventricular assist devices (VAD) have been developed, and the utilization of these devices has grown exponentially. We discuss the most ...common temporary mechanical circulatory support (tMCS) devices used for patients in cardiogenic shock, including the intra-aortic balloon pump (IABP), transvalvular axial flow support systems (Impella®), the Tandem™ collection, and extracorporeal membrane oxygenation (ECMO).
Recent Findings
In 2018 the United Network for Organ Sharing (UNOS) introduced new listing criteria for candidates awaiting heart transplantation in the USA. Analysis of the first 1300 transplants under these new listing criteria has shown that higher-risk patients are now undergoing transplantation.
Summary
As technology has advanced, becoming more sophisticated and miniaturized, a new era has emerged with more rapidly deployable tMCS devices. For some patients presenting in cardiogenic shock, support with these tMCS devices can be a bridge to a more durable option. For others, their only option may be support with the hope of native cardiac recovery. Understanding the pros and cons of each device can lead to most appropriate utilization for the ultimate intended goal.
In advanced heart failure patients implanted with a fully magnetically levitated HeartMate 3 (HM3, Abbott) left ventricular assist device (LVAD), it is unknown how preimplant factors and postimplant ...index hospitalization events influence 5-year mortality in those able to be discharged.
The goal was to identify risk predictors of mortality through 5 years among HM3 LVAD recipients conditional on discharge from index hospitalization in the MOMENTUM 3 pivotal trial.
This analysis evaluated 485 of 515 (94%) patients discharged after implantation of the HM3 LVAD. Preimplant (baseline), implant surgery, and index hospitalization characteristics were analyzed individually, and as multivariable predictors for mortality risk through 5 years.
Cumulative 5-year mortality in the cohort (median age: 62 years, 80% male, 65% White, 61% destination therapy due to transplant ineligibility) was 38%. Two preimplant characteristics (elevated blood urea nitrogen and prior coronary artery bypass graft or valve procedure) and 3 postimplant characteristics (hemocompatibility-related adverse events, ventricular arrhythmias, and estimated glomerular filtration rate <60 mL/min/1.73 m2 at discharge) were predictors of 5-year mortality. In 171 of 485 patients (35.3%) without any risk predictors, 5-year mortality was reduced to 22.6% (95% CI: 15.4%-32.7%). Even among those with 1 or more predictors, mortality was <50% at 5 years (45.7% 95% CI: 39.0%-52.8%).
Long-term survival in successfully discharged HM3 LVAD recipients is largely influenced by clinical events experienced during the index surgical hospitalization in tandem with baseline factors, with mortality of <50% at 5 years. In patients without identified predictors of risk, long-term 5-year mortality is low and rivals that achieved with heart transplantation, even though most were implanted with destination therapy intent. (MOMENTUM 3 IDE Clinical Study Protocol, NCT02224755; MOMENTUM 3 Pivotal Cohort Extended Follow-up PAS, NCT03982979)
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Left ventricular assist devices (LVADs) are increasingly utilized for patients with end-stage heart failure (HF). Pulmonary hypertension (PH) is highly prevalent in this patient population mainly due ...to prolonged left ventricular (LV) failure and chronically elevated filling pressures. The effect of LVADs on pulmonary circulation and right ventricular (RV) function has recently become an area of great attention in literature. PH can lead to post-LVAD right ventricular failure (RVF) that confers a high risk of morbidity and mortality. Multiple pulmonary vasodilators, that are primarily used for the treatment of pulmonary arterial hypertension (PAH), have been studied for the treatment of PH after LVAD implantation, and some of them have shown promising results. This review aims to investigate the treatment options for PH in patients on LVADs, as well as to give an overview about the pathophysiology of PH and RVF in these patients.
Although several electrocardiographic features of arrhythmogenic right ventricular cardiomyopathy (ARVC) (also called dysplasia) have been described, total 12-lead QRS voltage is not one of them. ...This report describes total 12-lead QRS voltage in 11 patients with ARVC who underwent orthotopic heart transplantation (OHT) because of progressively severe heart failure. Additionally, it illustrates the varied morphologic features of ARVC. The total 12-lead nonpaced QRS voltages before OHT ranged from 28 to 118 mm (mean 74 ± 32), and those in the paced tracings, from 33 to 129 mm (62 ± 32). The voltages are the lowest we have encountered among 12 previously reported cardiovascular conditions. The heart weights among the 11 ARVC patients ranged from 285 to 670 g (mean 448 ± 125). Very low 12-lead QRS voltage is characteristic of patients with ARVC with heart failure severe enough to warrant OHT, and thus may serve as a clue to its diagnosis.
Heart failure (HF) affects 6 million people in the United States and costs $30 billion annually. It is unclear whether improvements in length of stay and mortality over the last few decades hold true ...for both systolic and diastolic HF. To better assess the epidemiological and economic burden of HF, we assessed the trends in outcomes and costs for both systolic and diastolic HF. We identified hospitalizations for systolic and diastolic HF in the National Inpatient Sample database and evaluated trends over the period from 2004 to 2017, adjusting for demographics and co-morbidities. The proportion of patients admitted with an exacerbation of systolic HF increased from 42% to 63% over the study period. We found an overall decreasing trend between 2004 and 2011 in the length of stay for HF in general with a sharper decrease in diastolic than systolic HF. Inpatient mortality decreased between 2004 and 2007 and stabilized between 2008 and 2016. Systolic HF was associated with higher mortality than diastolic HF. The total inflation-adjusted cost did not change significantly over the study period, with systolic HF costing, on average, $3,036 more than diastolic HF per admission. In conclusion, systolic HF overtook diastolic HF, accounting for most HF hospitalizations in 2008. The higher hospitalization costs for systolic HF relative to diastolic HF may have resulted, in part, from greater use of advanced support devices in patients with systolic HF.
The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled ...by an international panel of experts based on an extensive literature review.
Mycophenolate mofetil (MMF), the prodrug of mycophenolic acid, is a highly effective immunosuppressive agent in heart transplant therapy. While the FDA approved dose is 1500 mg twice daily, dosing is ...often reduced due to dose‐dependent adverse effects. However, empiric MMF dose reductions may lead to sub‐therapeutic dosing and impair clinical outcomes. Our single center protocolized a risk‐stratified approach based on age and weight to dose 500 mg twice daily or 1000 mg twice daily to patients after heart transplantation. This retrospective single‐center study analyzed 140 consecutive heart transplant patients who were initiated on our risk‐stratified MMF protocol post‐transplant. The analysis revealed that the composite rate of biopsy‐proven rejection, graft loss, or mortality at 1‐year post‐transplantation was similar between the two groups. Incidence of neutropenia, thrombocytopenia, infection, cardiac allograft vasculopathy, or acute kidney injury by 1‐year also showed similar results between the two groups. Risk‐stratification of MMF dosing appears to be a safe and effective strategy after heart transplantation.
