Restructuring the Heart From Failure to Success: Role of Structural Interventions in the Realm of Heart Failure

Heart failure through the spectrum of reduced (HFrEF), mid-range (or mildly reduced or HFmEF), and preserved ejection fraction (HFpEF), continues to plague patients' quality of life through recurrent admissions and high mortality rates. Despite tremendous innovation in medical therapy, patients continue to experience refractory congestive symptoms due to adverse left ventricular remodeling, significant functional mitral regurgitation (FMR), and right-sided failure symptoms due to significant functional tricuspid regurgitation (FTR). As most of these patients are surgically challenging for open cardiac surgery, the past decade has seen the development and evolution of different percutaneous structural interventions targeted at improving FMR and FTR. There is renewed interest in the sphere of left ventricular restorative devices to effect reverse remodeling and thereby improve effective stroke volume and patient outcomes. For patients suffering from HFpEF, there is still a paucity of disease-modifying effective medical therapies, and these patients continue to have recurrent heart failure exacerbations due to impaired left ventricular relaxation and high filling pressures. Structural therapies involving the implantation of inter-atrial shunt devices to decrease left atrial pressure and the development of implantable devices in the pulmonary artery for real-time hemodynamic monitoring would help redefine treatment and outcomes for patients with HFpEF. Lastly, there is pre-clinical data supportive of soft robotic cardiac sleeves that serve to improve cardiac function, can assist contraction as well as relaxation of the heart, and have the potential to be customized for each patient. In this review, we focus on the role of structural interventions in heart failure as it stands in current clinical practice, evaluate the evidence amassed so far, and review promising structural therapies that may transform the future of heart failure management

Malignancy: An Adverse Effect of Immunosuppression

Benefits of solid organ transplantation in end stage organ diseases are indisputable. Malignancy is a feared complication of solid organ transplantation and is a leading cause of mortality in patients with organ transplantation. Iatrogenic immunosuppression to prevent graft rejection plays a crucial role in the cancer development in solid organ transplant recipients. Chronic exposure to immunosuppression increases the malignancy burden through deregulation of host immune defense mechanisms and unchecked proliferation of oncogenic viruses and malignancies associated with these viruses. Vigorous screening of candidates undergoing transplant evaluation for malignancies, careful assessment of donors, and vigilant monitoring of transplant recipients are necessary to prevent, detect, and manage this life-threatening complication

Managing Cardiovascular Risk in the Post Solid Organ Transplant Recipient

Solid organ transplantation is an effective treatment for patients with end-stage organ disease. The prevalence of cardiovascular diseases (CVD) has increased in recipients. CVD remains a leading cause of mortality among recipients with functioning grafts. The pathophysiology of CVD recipients is a complex interplay between preexisting risk factors, metabolic sequelae of immunosuppressive agents, infection, and rejection. Risk modification must be weighed against the risk of mortality owing to rejection or infection. Aggressive risk stratification and modification before and after transplantation and tailoring immunosuppressive regimens are essential to prevent complications and improve short-term and long-term mortality and graft survival

What Is the Status of Regenerative Therapy in Heart Failure?

Purpose of Review Heart failure remains a major public health concern with high burden of morbidity and mortality despite advances in pharmacotherapy, device therapy, and surgical and percutaneous techniques. Cardiac regeneration may have a role to play in these patients with a huge unmet need for these therapies in patients with chronic ischemic heart disease, post-infarct heart failure, dilated cardiomyopathy, and heart failure with preserved ejection fraction. Recent Findings In this review, we focus on the pre-clinical and translational basis for different modes of cardiac regenerative medicine and then critically appraise the clinical evidence amassed from pivotal clinical trials focused on cardiac regeneration for ischemic and non-ischemic cardiomyopathies. Cardiac regenerative medicine is rapidly evolving with novel approaches involving cell-based, cell-free, tissue engineering, and hybrid therapies to achieve myocardial regeneration and repair. Further studies are warranted with a robust comparison arm with optimal contemporary medical therapy to translate regenerative therapies to a clinical reality

Women in mechanical circulatory support: She persisted

Many women physicians have blazed trails and played instrumental roles in advancing the field of Advanced Heart Failure (AHF), Mechanical Circulatory Support (MCS), and cardiac transplantation to its current recognition and glory. In contrast to other areas of cardiology, women have played an integral role in the evolution and emergence of this sub-specialty. Although the ceiling had been broken much later for women cardiothoracic (CT) surgeons in the field of AHF, the ingress of women into surgical fields particularly CT surgery was stonewalled due to pervasive stereotyping. The constancy, commitment, and contributions of women to the field of AHF and MCS cannot be minimized in bringing this field to the forefront of innovation both from technological aspect as well as in redesigning of healthcare delivery models. Integrated team-based approach is a necessity for the optimal care of MCS patients and forced institutions to develop this approach when patients with durable left ventricular assist devices (LVAD) began discharging from the hospitals to local communities. Women in various roles in this field played a pivotal role in developing and designing patient centered care and coordination of care in a multidisciplinary manner. While embracing the challenges and turning them to opportunities, establishing partnerships and finding solutions with expectations to egalitarianism, women in this field continue to push boundaries and subscribe to the continued evolution of the field of AHF and advanced cardiac therapies

Abstract 12772: In Hospital Outcomes With Extracorporeal Membrane Oxygenation Alone vs Combined With Percutaneous Left Ventricular Assist Device

Abstract only Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is often used to support patients with cardiogenic shock. However, it is associated with an increase in systemic afterload which can lead to worsening cardiac function. The use of a percutaneous left ventricular assist device (pLVAD) plus ECMO has emerged as a strategy to offload the left ventricle, with some studies showing improved outcomes. Hypothesis: The use of ECMO plus pLVAD is associated with improved outcomes compared to the use of EMCO alone. Methods: The National Inpatient Sample was queried from 2011-2018 for relevant ICD-9 and ICD-10 codes to identify patients with cardiogenic shock supported with ECMO or ECMO plus a pLVAD (Ecpella) during the same admission. Baseline characteristics and in-hospital outcomes between groups were compared. Logistic regression was performed to adjust for pre-specified co-variates for outcomes. p-value was considered significant if <0.001. Results: Of 20,171 patients with cardiogenic shock supported with ECMO, 16,064 (79.6%) were treated with only ECMO and 4,107 (20.4%) were treated with ECMO plus pLVAD. Patients in the Ecpella group were more likely to be male (72% vs 66%), have a history of hypertension (50% vs 47%), diabetes (21% vs 15%), chronic kidney disease (27% vs 22%), coronary artery disease (54% vs 44%), myocardial infarction (6% vs 4%, p<0.001 for all). Age (55.6 vs 55.2 years (p = 0.09) and rate of atrial fibrillation and flutter were not significantly different. After adjusting for significant variables, patients in the Ecpella group, had higher rates of mortality (OR 1.2; CI [1.1-1.3]), stroke (OR 1.3; CI [1.2-1.5]), and major bleeding (OR 1.5; CI [1.4-1.7], p < 0.001 for all). The rate of inpatient dialysis was lower in the Ecpella group (OR 0.7; CI 0.7-0.8; p < 0.001). Conclusions: Cardiogenic shock patients treated with ECMO plus pLVAD had worse outcomes compared to patients treated with ECMO alone. Although it is possible that patients treated with ECMO plus pLVAD had a more critical presentation, further studies are needed to evaluate these findings

Algorithm for Treatment of Advanced Heart Failure

Heart failure is a growing epidemic worldwide that confers a substantial medical and economic burden on our society. With the aging population and the improved treatment strategies made available over the last several decades including neurohormonal blockade, cardiac resynchronization, and multidisciplinary psychosocial interventions, the prevalence of advanced heart failure is increasing as patients with heart failure are living longer with parallel progression of their disease state. Judicious risk stratification and cautious patient selection are paramount in guiding appropriate therapies. It is imperative to understand the underlying pathophysiology, decision-making strategies, pharmacologic therapies, and comprehensive options in managing advanced heart failure. For patients who exhaust the widely available medical and surgical therapies, then additional algorithms and multidisciplinary decision teams must be in place for consideration of cardiac transplant or mechanical circulatory support device in this subcohort of advanced, end-stage heart failure

In-hospital outcomes with extracorporeal membrane oxygenation alone versus combined with percutaneous left ventricular assist device

Veno-arterial extracorporeal membrane oxygenation (ECMO) is associated with increased afterload and hindered myocardial recovery. Adding a percutaneous left ventricular assist device (pLVAD) to ECMO is one strategy to unload the left ventricle. We evaluated in-hospital outcomes in cardiogenic shock patients treated with ECMO alone versus ECMO plus pLVAD. We conducted a retrospective study using the National Inpatient Sample database from 2011 to 2019. Logistic regression analysis was performed to adjust for covariates. 20,171 patients were included. 16,064 (79.6 %) patients received ECMO alone and 4107 (20.4 %) patients received ECMO plus pLVAD. The ECMO plus pLVAD group had higher rates of mortality, stroke, acute kidney injury, pericardial complications, and vascular complications. After adjusting for covariates, combined therapy was associated with higher rates of mortality (OR 1.2; 95 % CI [1.1-1.3]) and stroke (OR 1.3; 95 % CI [1.2-1.5]), however lower bleeding (OR 0.7; 95 % CI [0.68-0.81]) (p < 0.001 for all). After adjusting for covariates, a subgroup analysis of 5019 patients with acute coronary syndrome cardiogenic shock (ACS-CS) demonstrated higher rates of mortality (OR 1.3; 95 % CI [1.2-1.5]) and stroke (OR 1.7; 95 % CI [1.4-2.1]; p < 0.001 for all) with combined therapy, however similar rates of bleeding compared to ECMO alone (OR 0.95; 95 % CI [0.8-1.1]; p = 0.54). In the overall group, ECMO plus pLVAD was associated with increased mortality and stroke, however decreased bleeding. In a sub-group of ACS-CS, ECMO plus pLVAD was associated with increased mortality and stroke, however similar rates of bleeding compared to ECMO alone

Sex Differences in Circulating Biomarkers of Heart Failure

PURPOSE OF REVSIEWEvidence is scaling up for sex differences in heart failure; however, clinical relevance of sex-specific differential thresholds for biomarkers is not clearly known. Current ambiguity warrants a further look into the sex-specific studies on cardiac biomarkers and may facilitate understanding of phenotypic presentations, clinical manifestations, and pathophysiologic pathway differences in men and women.RECENT FINDINGSRecent studies have confirmed the fact that females have differential threshold for biomarkers, with lower troponin and higher NT proBNP levels. Ambiguity continues to exist in the clinical relevance of ST-2, Galectin 3, and other biomarkers. Novel biomarkers, proteomic biomarkers, and circulating micro RNAs with machine learning are actively being explored. Biomarkers in HFpEF patients with higher female representation are evolving. In recent clinical trials, sex-related difference in biomarkers is not seen despite therapeutic intervention being more effective in females compared to males. Sex-related difference exists in the expression of biomarkers in health and in various disease states of heart failure. However, this differentiation has not effectively translated into the clinical practice in terms of diagnostic studies or prognostication. Active exploration to bridge the knowledge gap and novel technologies can shed more light in this area