Normalization of Pulmonary Hypertension by the Use of Left Ventricular Assist Device in Patients with End-stage Heart Failure: A Possible Contribution to Donor Pool Expansion in Lung Transplantation

SummaryHeart transplantation alone has been recognized to be contraindicated when pulmonary hypertension (PH) and elevated pulmonary vascular resistance (PVR) are irreversible, irrespective of any medical intervention by the use of inotropic agents or pulmonary vasodilators, because such patients are at an increased risk of post-transplantation right ventricular failure and mortality. Therefore, end-stage heart failure patients with concomitant fixed PH and irreversibly high PVR are considered to be heart–lung transplant candidates. Recently, left ventricular assist device (LVAD) therapy has been reported to normalize PVR through persistent unloading of the left ventricle, even in patients with medically refractory PH. Therefore, LVAD therapy could make such patients suitable for “heart-only” transplants, which contributes to appropriate donor lung allocation for lung-only candidates. We review the literature regarding LVAD use for secondary PH and present a case with end-stage heart failure that could avoid a heart–lung transplant owing to LVAD therapy

Recent Advances in the Diagnosis and Management of Cirrhosis-Associated Cardiomyopathy in Liver Transplant Candidates: Advanced Echo Imaging, Cardiac Biomarkers, and Advanced Heart Failure Therapies

Patients with end-stage liver disease in need of liver transplantation increasingly are older with a greater burden of cardiac disease and other co-morbidities, which may increase perioperative risk and adversely affect long-term prognosis. Cirrhosis of any etiology manifests hemodynamically as a state of low systemic vascular resistance, with high peripheral, but low central blood volume, leading to a state of neurohormonal activation and high cardiac output, which may adversely affect cardiac reserve under extreme perioperative stress, aptly termed cirrhosis-associated or cirrhotic cardiomyopathy. Evidence of asymptomatic cirrhotic cardiomyopathy may be found in subtle electrocardiographic and echocardiographic changes, but may progress to severe heart failure under the demands of bleeding and transfusions, vasopressors, rebounding peripheral vascular resistance, withdrawal of cardioprotective beta-blockers and mineralocorticoid antagonists, exacerbated by sepsis or systemic inflammatory response syndrome. This review will add to the current body of literature on cirrhotic cardiomyopathy by focusing on the role of advanced echocardiographic imaging techniques, cardiac biomarkers, and advanced heart failure therapies available to manage patients with cirrhotic cardiomyopathy while waiting for liver transplant and during the perioperative period

Interim analysis of the INTERPRET patient registry program of advanced heart failure patients treated with intravenous inotropes in the ambulatory setting

INTRODUCTION: Inotropic therapy has been associated with increased risk of arrhythmic events and reduced survival, yet inotropes continue to be prescribed for either palliative care or as a bridge to cardiac transplantation or a ventricular assist device (VAD). We conducted an interim analysis of the Inotrope, Evaluation and Research (INTERPRET) Patient Registry Program, a contemporary registry of advanced heart failure patients receiving continuous inotropic therapy in the ambulatory setting. METHODS: This is a multi-center, prospective, observational registry study. All patients prescribed intravenous dobutamine, dopamine, or milrinone for continuous home use and who utilized the Coram CVS Specialty vendor were eligible to participate. Outcome measures included mean time of survival on inotropes, frequency and cause of hospital readmission, arrhythmia burden including ICD shocks, patient symptoms on a 10 point scale, quality of life scores using the Kansas City Cardiomyopathy-12 (KCCQ-12) questionnaire. RESULTS: Twenty two patients have been enrolled in the study. The average age the patients was 59 yrs (range 18–83) and the majority were male (86%). Reason for inotrope use was as a bridge to transplant (25%) or VAD (25%), as palliative care (32%), or as a temporary bridge to optimizing medical therapy (18%). Six of the patients have died (2 of which were on palliative inotropes) with an average survival time of 92 days (range 33–188). Five out of 22 patients (18%) were re-hospitalized within 30 days of discharge, none due to arrhythmia. Baseline KCCQ-12 summary scores averaged 43.2 (range 0.0–82.6). Overall, patient symptoms improved during the mean follow up of 8.4 weeks, including improvements in average scores for dyspnea on exertion (5.1– \u3e 2.8), fatigue (5.3-\u3e3.8) and pain (2.3-\u3e1.3). CONCLUSIONS: An interim analysis of the INTERPRET Patient Registry reveals a nearly even distribution between palliative, bridge to transplant, and bridge to VAD patients. Overall, patients report an improvement in dyspnea with exertion and fatigue during the short term. Future analyses of the complete registry will be required to determine whether inotropes can successfully improve patient symptoms in the short term while minimizing the need for rehospitalization until either a successful bridge to therapy or death

Impact of Female Sex on Cardiogenic Shock Outcomes: A Cardiogenic Shock Working Group Report

BACKGROUND: Studies reporting cardiogenic shock (CS) outcomes in women are scarce. OBJECTIVES: The authors compared survival at discharge among women vs men with CS complicating acute myocardial infarction (AMI-CS) and heart failure (HF-CS). METHODS: The authors analyzed 5,083 CS patients in the Cardiogenic Shock Working Group. Propensity score matching (PSM) was performed with the use of baseline characteristics. Logistic regression was performed for log odds of survival. RESULTS: Among 5,083 patients, 1,522 were women (30%), whose mean age was 61.8 ± 15.8 years. There were 30% women and 29.1% men with AMI-CS (P = 0.03). More women presented with de novo HF-CS compared with men (26.2% vs 19.3%; P \u3c 0.001). Before PSM, differences in baseline characteristics and sex-specific outcomes were seen in the HF-CS cohort, with worse survival at discharge (69.9% vs 74.4%; P = 0.009) and a higher rate of maximum Society for Cardiac Angiography and Interventions stage E (26% vs 21%; P = 0.04) in women than in men. Women were less likely to receive pulmonary artery catheterization (52.9% vs 54.6%; P \u3c 0.001), heart transplantation (6.5% vs 10.3%; P \u3c 0.001), or left ventricular assist device implantation (7.8% vs 10%; P = 0.01). Regardless of CS etiology, women had more vascular complications (8.8% vs 5.7%; P \u3c 0.001), bleeding (7.1% vs 5.2%; P = 0.01), and limb ischemia (6.8% vs 4.5%; P = 0.001). More vascular complications persisted in women after PSM (10.4% women vs 7.4% men; P = 0.06). CONCLUSIONS: Women with HF-CS had worse outcomes and more vascular complications than men with HF-CS. More studies are needed to identify barriers to advanced therapies, decrease complications, and improve outcomes of women with CS

Outcomes of COVID‐19 in solid organ transplant recipients: A matched cohort study

Whether solid organ transplant (SOT) recipients are at increased risk of poor outcomes due to COVID‐19 in comparison to the general population remains uncertain. In this study, we compared outcomes of SOT recipients and non‐SOT patients hospitalized with COVID‐19 in a propensity score matched analysis based on age, race, ethnicity, BMI, diabetes, and hypertension. After propensity matching, 117 SOT recipients and 350 non‐SOT patients were evaluated. The median age of SOT recipients was 61 years, with a median time from transplant of 5.68 years. The most common transplanted organs were kidney (48%), followed by lung (21%), heart (19%), and liver (10%). Overall, SOT recipients were more likely to receive COVID‐19 specific therapies and to require ICU admission. However, mortality (23.08% in SOT recipients vs. 23.14% in controls, P = .21) and highest level of supplemental oxygen (P = .32) required during hospitalization did not significantly differ between groups. In this propensity matched cohort study, SOT recipients hospitalized with COVID‐19 had similar overall outcomes as non‐SOT recipients, suggesting that chronic immunosuppression may not be an independent risk factor for poor outcomes in COVID‐19