Anomalous Origin of the Right Coronary Artery Causing Myocardial Ischemia: A Case for a Multimodality Imaging Approach

A 46-year-old man was admitted with non-ST elevation myocardial infarction and newly diagnosed acutely decompensated heart failure. Echocardiogram demonstrated left ventricular ejection fraction of 30% with basal inferior and inferolateral akinesis. Coronary angiography showed mild diffuse coronary artery disease and an anomalous right coronary artery arising from the left coronary cusp. Further imaging was consistent with ischemia in the right coronary distribution. Etiology of ischemia was thought to be the anomalous right coronary artery, and surgical unroofing of the right coronary ostium was performed. Here, we report a multimodality imaging approach, including cardiac magnetic resonance, cardiac computed tomographic angiography, and single-photon emission computed tomography, to support the diagnosis and management of a patient with anomalous right coronary artery arising from the left coronary cusp

Characteristics and Predictors of Late Right Heart Failure after Left Ventricular Assist Device Implantation

Late right heart failure (LRHF) following left ventricular assist device (LVAD) implantation remains poorly characterized and challenging to predict. We performed a multicenter retrospective study of LRHF in 237 consecutive adult LVAD patients, in which LRHF was defined according to the 2020 Mechanical Circulatory Support Academic Research Consortium guidelines. Clinical and hemodynamic variables were assessed pre- and post-implant. Competing-risk regression and Kaplan-Meier survival analysis were used to assess outcomes. LRHF prediction was assessed using multivariable logistic and Cox proportional hazards regression. Among 237 LVAD patients, 45 (19%) developed LRHF at a median of 133 days post-LVAD. LRHF patients had more frequent heart failure hospitalizations (p 35 mg/dl at 1 month post-LVAD, and diuretic requirements at 1 month post-LVAD were each significant, independent predictors of LRHF in multivariable analysis. An LRHF prediction risk score incorporating these variables predicted LRHF with excellent discrimination (log-rank p < 0.0001). Overall, LRHF post-LVAD is more common than generally appreciated, with significant morbidity and mortality. Elevated PVR and precapillary pulmonary pressures may play a role. A risk score using early right heart failure, elevated BUN, and diuretic requirements 1 month post implant predicted the development of LRHF

Characteristics and Predictors of Late Right Heart Failure After Left Ventricular Assist Device Implantation.

Late right heart failure (LRHF) following left ventricular assist device (LVAD) implantation remains poorly characterized and challenging to predict. We performed a multicenter retrospective study of LRHF in 237 consecutive adult LVAD patients, in which LRHF was defined according to the 2020 Mechanical Circulatory Support Academic Research Consortium guidelines. Clinical and hemodynamic variables were assessed pre- and post-implant. Competing-risk regression and Kaplan-Meier survival analysis were used to assess outcomes. LRHF prediction was assessed using multivariable logistic and Cox proportional hazards regression. Among 237 LVAD patients, 45 (19%) developed LRHF at a median of 133 days post-LVAD. LRHF patients had more frequent heart failure hospitalizations ( p \u3c 0.001) alongside other complications. LRHF patients did not experience reduced bridge-to-transplant rates but did suffer increased mortality (hazard ratio 1.95, 95% confidence interval [CI] 1.11-3.42; p = 0.02). Hemodynamically, LRHF patients demonstrated higher right atrial pressure, mean pulmonary arterial pressure, and pulmonary vascular resistance (PVR), but no difference in pulmonary arterial wedge pressure. History of early right heart failure, blood urea nitrogen (BUN) \u3e 35 mg/dl at 1 month post-LVAD, and diuretic requirements at 1 month post-LVAD were each significant, independent predictors of LRHF in multivariable analysis. An LRHF prediction risk score incorporating these variables predicted LRHF with excellent discrimination (log-rank p \u3c 0.0001). Overall, LRHF post-LVAD is more common than generally appreciated, with significant morbidity and mortality. Elevated PVR and precapillary pulmonary pressures may play a role. A risk score using early right heart failure, elevated BUN, and diuretic requirements 1 month post implant predicted the development of LRHF

Impact of preoperative liver dysfunction on outcomes in patients with left ventricular assist devices

OBJECTIVES: We evaluated the impact of preoperative liver function on early and 1-year postoperative outcomes in patients supported with a left ventricular assist device (LVAD) and subsequent evolution of liver function markers. METHODS: A retrospective multicentre cohort study was conducted, including all patients undergoing continuous-flow LVAD implantation. The Model for End-stage Liver Disease (MELD) score was used to define liver dysfunction. RESULTS: Overall, 290 patients with an LVAD [78% HeartMate II, 15% HVAD and 7% HeartMate 3, mean age 55 (18), 76% men] were included. Over 40 000 measurements of liver function markers were collected over a 1-year period. A receiver operating characteristic curve analysis for the 1-year mortality rate identified the optimal cut-off value of 12.6 for the MELD score. Therefore, the cohort was dichotomized into patients with an MELD score of less than or greater than 12.6. The early (90-day) survival rates in patients with and without liver dysfunction were 76% and 91% (P = 0.002) and 65% and 90% at 1 year, respectively (P < 0.001). Furthermore, patients with preoperative liver dysfunction had more embolic events and more re-explorations. At the 1-year follow-up, liver function markers showed an overall improvement in the majority of patients, with or without pre-LVAD liver dysfunction. CONCLUSIONS: Preoperative liver dysfunction is associated with higher early 90-day and 1-year mortality rates after LVAD implantation. Furthermore, liver function improved in both patient groups. It has become imperative to optimize the selection criteria for possible LVAD candidates, since those who survive the first year show excellent recovery of their liver markers