Hemodynamics and Kinetics of Heart Failure with Preserved Ejection Fraction Shock

The classical paradigm of cardiogenic shock is severe impairment of left ventricular, right ventricular, or biventricular contractility resulting in decreased cardiac output and end-organ failure. In patients with preserved ejection fraction, cardiogenic shock results from impaired left ventricular filling leading to decreased cardiac output and end-organ hypoperfusion. Heart failure with preserved ejection fraction (HFpEF) comprises a heterogenous group of myocardial and systemic metabolic derangements. Cardiogenic shock with preserved left ventricular ejection is thought to be less common than with reduced left ventricular ejection fraction, and therapeutic approaches are not well standardized. We aim to review the pathophysiology of cardiogenic shock in HFpEF, define various etiologies that culminate in the HFpEF shock state, and present our algorithmic approach to managing these complex patients

Acute Left Atrial Compression after Ventricular Assist Device Placement

Highlights: Pump thrombosis commonly presents with hemolysis and device parameter fluctuations. Left atrial compression presents similarly to pump thrombosis but with no device fluctuations. Reference standard imaging test for ventricular device thrombus is contrast-enhanced CT

The Anemia Stress Index-Anemia, Transfusions, and Mortality in Patients with Continuous Flow Ventricular Assist Devices

We aimed to identify a simple metric accounting for peri-procedural hemoglobin changes, independent of blood product transfusion strategies, and assess its correlation with outcomes in patients undergoing left ventricular assist device (LVAD) implantation We included consecutive patients undergoing LVAD implantation at a single center between 10/1/2008 and 6/1/2014. The anemia stress index (ASI), defined as the sum of number of packed red blood cells transfused and the hemoglobin changes after LVAD implantation, was calculated for each patient at 24 h, discharge, and 3 months after LVAD implantation. Our cohort included 166 patients (80.1% males, mean age 56.3 ± 15.6 years) followed up for a median of 12.3 months. Increases in ASI per unit were associated with a higher hazard for all-cause mortality and early RV failure. The associations between the ASI and all-cause mortality persisted after multivariable adjustment, irrespective of when it was calculated (adjusted HR of 1.11, 95% CI 1.03-1.20 per unit increase in ASI). Similarly, ASI at 24 h after implant was associated with early RV failure despite multivariable adjustment (OR 1.09, 95% CI 1.05-1.14). We present a novel metric, the ASI, that is correlated with an increased risk for all-cause mortality and early RV failure in LVAD recipients

Predicting Long Term Outcome in Patients Treated With Continuous Flow Left Ventricular Assist Device: The Penn—Columbia Risk Score

Background: Predicting which patients are unlikely to benefit from continuous flow left ventricular assist device (LVAD) treatment is crucial for the identification of appropriate patients. Previously developed scoring systems are limited to past eras of device or restricted to specific devices. Our objective was to create a risk model for patients treated with continuous flow LVAD based on the preimplant variables. Methods and Results: We performed a retrospective analysis of all patients implanted with a continuous flow LVAD between 2006 and 2014 at the University of Pennsylvania and included a total of 210 patients (male 78%; mean age, 56±15; mean follow‐up, 465±486 days). From all plausible preoperative covariates, we performed univariate Cox regression analysis for covariates affecting the odds of 1‐year survival following implantation (P<0.2). These variables were included in a multivariable model and dropped if significance rose above P=0.2. From this base model, we performed step‐wise forward and backward selection for other covariates that improved power by minimizing Akaike Information Criteria while maximizing the Harrell Concordance Index. We then used Kaplan–Meier curves, the log‐rank test, and Cox proportional hazard models to assess internal validity of the scoring system and its ability to stratify survival. A final optimized model was identified based on clinical and echocardiographic parameters preceding LVAD implantation. One‐year mortality was significantly higher in patients with higher risk scores (hazard ratio, 1.38; P=0.004). This hazard ratio represents the multiplied risk of death for every increase of 1 point in the risk score. The risk score was validated in a separate patient cohort of 260 patients at Columbia University, which confirmed the prognostic utility of this risk score (P=0.0237). Conclusion: We present a novel risk score and its validation for prediction of long‐term survival in patients with current types of continuous flow LVAD support

Mechanical Circulatory Support as a Bridge to Transplant or for Destination Therapy

Mechanical circulatory support (MCS) frequently is used to treat medically refractory end-stage heart failure. Initially designed to be a bridge to transplantation, MCS also has proven itself as a durable therapy for patients who are not transplant candidates. As outcomes for patients with MCS have improved, research interest in device development has flourished, with many new device types under investigation. In addition to improvement of MCS devices, investigational work continues to achieve appropriate patient selection and complication management