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Wei J, Franke J, Kee A, Dukes R, Leonardo V, Flynn BC. Postoperative Pulmonary Artery Pulsatility Index Improves Prediction of Right Ventricular Failure After Left Ventricular Assist Device Implantation. J Cardiothorac Vasc Anesth 2024; 38:214-220. [PMID: 37973507 DOI: 10.1053/j.jvca.2023.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/22/2023] [Accepted: 10/05/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES This study evaluated whether the postoperative pulmonary artery pulsatility index (PAPi) is associated with postoperative right ventricular dysfunction after durable left ventricular assist device (LVAD) implantation. DESIGN Single-center retrospective observational cohort study. SETTING The University of Kansas Medical Center, a tertiary-care academic medical center. PARTICIPANTS Sixty-seven adult patients who underwent durable LVAD implantation between 2017 and 2019. INTERVENTIONS All patients underwent open cardiac surgery with cardiopulmonary bypass under general anesthesia with pulmonary artery catheter insertion. MEASUREMENTS AND MAIN RESULTS Clinical and hemodynamic data were collected before and after surgery. The Michigan right ventricular failure risk score and the European Registry for Patients with Mechanical Circulatory Support score were calculated for each patient. The primary outcome was right ventricular failure, defined as a composite of right ventricular mechanical circulatory support, inhaled pulmonary vasodilator therapy for 48 hours or greater, or inotrope use for 14 days or greater or at discharge. Thirty percent of this cohort (n = 20) met the primary outcome. Preoperative transpulmonary gradient (odds ratio [OR] 1.15, 95% CI 1.02-1.28), cardiac index (OR 0.83, 95% CI 0.71-0.98), and postoperative PAPi (OR 0.85, 95% CI 0.75-0.97) were the only hemodynamic variables associated with the primary outcome. The addition of postoperative PAPi was associated with improvement in the predictive model performance of the Michigan score (area under the receiver operating characteristic curve 0.73 v 0.56, p = 0.03). An optimal cutoff point for postoperative PAPi of 1.56 was found. CONCLUSIONS The inclusion of postoperative PAPi offers more robust predictive power for right ventricular failure in patients undergoing durable LVAD implantation, compared with the use of existing risk scores alone.
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Affiliation(s)
- Johnny Wei
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS.
| | - Jack Franke
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Abigail Kee
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Rachel Dukes
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Vincent Leonardo
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Brigid C Flynn
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
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Read JM, Azih NI, Peters CJ, Gurtu V, Vishram-Nielsen JK, Wright SP, Alba AC, Gregoski MJ, Pilch NA, Hsu S, Genuardi MV, Inampudi C, Jackson GR, Pope N, Witer LP, Kilic A, Houston BA, Mak S, Birati EY, Tedford RJ. Hemodynamic reserve predicts early right heart failure after LVAD implantation. J Heart Lung Transplant 2022; 41:1716-1726. [PMID: 35934606 PMCID: PMC10729844 DOI: 10.1016/j.healun.2022.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 06/09/2022] [Accepted: 07/05/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Early right heart failure (RHF) remains a major source of morbidity and mortality after left ventricular assist device (LVAD) implantation, yet efforts to predict early RHF have proven only modestly successful. Pharmacologic unloading of the left ventricle may be a risk stratification approach allowing for assessment of right ventricular and hemodynamic reserve. METHODS We performed a multicenter, retrospective analysis of patients who had undergone continuous-flow LVAD implantation from October 2011 to April 2020. Only those who underwent vasodilator testing with nitroprusside during their preimplant right heart catheterization were included (n = 70). Multivariable logistic regression was used to determine independent predictors of early RHF as defined by Mechanical Circulatory Support-Academic Research Consortium. RESULTS Twenty-seven patients experienced post-LVAD early RHF (39%). Baseline clinical characteristics were similar between patients with and without RHF. Patients without RHF, however, achieved higher peak stroke volume index (SVI) (30.1 ± 8.8 vs 21.7 ± 7.4 mL/m2; p < 0.001; AUC: 0.78; optimal cut-point: 22.1 mL/m2) during nitroprusside administration. Multivariable analysis revealed that peak SVI was significantly associated with early RHF, demonstrating a 16% increase in risk of early RHF per 1 ml/m2 decrease in SVI. A follow up cohort of 10 consecutive patients from July 2020 to October 2021 resulted in all patients being categorized appropriately in regards to early RHF versus no RHF according to peak SVI. CONCLUSION Peak SVI with nitroprusside administration was independently associated with post-LVAD early RHF while resting hemodynamics were not. Vasodilator testing may prove to be a strong risk stratification tool when assessing LVAD candidacy though additional prospective validation is needed.
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Affiliation(s)
| | | | - Carli J Peters
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Vikram Gurtu
- Division of Cardiology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Julie K Vishram-Nielsen
- Division of Cardiology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Stephen P Wright
- Division of Cardiology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Ana Carolina Alba
- Division of Cardiology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Mathew J Gregoski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Nicole A Pilch
- Deparment of Pharmacy, Medical University of South Carolina, Charleston, SC
| | - Steven Hsu
- Division of Cardiology, Department of Medicine, John Hopkins School of Medicine, Baltimore, MD
| | - Michael V Genuardi
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Gregory R Jackson
- Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Nicholas Pope
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Lucas P Witer
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Brian A Houston
- Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Susanna Mak
- Division of Cardiology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Edo Y Birati
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Cardiovascular Division, Poriya Medical Center, Bar Ilan University, Isreal
| | - Ryan J Tedford
- Division of Cardiology, Medical University of South Carolina, Charleston, SC.
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Cacioli G, Polizzi V, Ciabatti M, Cristiano E, Pergolini A, Distefano G, Lilla Della Monica P, Comisso M, Piazza V, Sbaraglia F, Musumeci F. Prediction of right ventricular failure after left ventricular assist device implantation: role of vasodilator challenge. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:629-639. [PMID: 35866303 DOI: 10.1093/ehjacc/zuac085] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 07/04/2022] [Accepted: 07/08/2022] [Indexed: 01/01/2023]
Abstract
AIMS Pulmonary artery pulsatility index (PAPi) is an indicator of right ventricular (RV) function and an independent predictor of right ventricular failure (RVF) following left ventricular assist device (LVAD) implantation. Administration of vasodilator challenge during right heart catheterization (RHC) could reduce RV workload allowing a better assessment of its functional reserve. METHODS AND RESULTS Patients undergoing LVAD implantation at our Institution between May 2013 and August 2021 were enrolled. Only patients who had undergone RHC and vasodilator challenge with sodium nitroprusside were analyzed. We collected all available clinical, instrumental, and haemodynamic parameters, at baseline and after nitroprusside infusion and evaluated potential associations with post-LVAD RVF. Of the 54 patients analyzed, 19 (35%) developed RVF after LVAD implantation. Fractional area change (FAC) (OR: 0.647, CI: 0.481-0.871; P = 0.004), pulmonary artery systolic pressure (PASP) (OR: 0.856, CI: 0.761-0.964; P = 0.010), and post-sodium nitroprusside (NTP) PAPi (OR: 0.218, CI: 0.073-0.653; P = 0.006) were independent predictors of post-LVAD RVF. The model combining FAC, PASP, and post-NTP PAPi demonstrated a predictive accuracy of 90.7%. Addition of post-NTP PAPi significantly increased the predictive accuracy of the European Registry for Patients with Mechanical Circulatory Support right-sided heart failure risk score [79.4 vs. 70.4%; area under the curve (AUC): 0.841 vs. 0.724, P = 0.022] and the CRITT score (79.6% vs. 74%; AUC: 0.861 vs. 0.767 P = 0.033). CONCLUSION Post-NTP PAPi has observed to be an independent predictor of RVF following LVAD implantation. Dynamic assessment of PAPi using a vasodilator challenge may represent a method of testing RV functional reserve in candidates for LVAD implantation. Larger and prospective studies are needed to confirm this hypothesis.
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Affiliation(s)
- Giulio Cacioli
- Cardiac Surgery and Heart Transplant Unit, Azienda Ospedaliera San Camillo Forlanini, Roma
| | - Vincenzo Polizzi
- Cardiac Surgery and Heart Transplant Unit, Azienda Ospedaliera San Camillo Forlanini, Roma
| | | | - Ernesto Cristiano
- Division of Cardiology, Department of Clinical and Molecular Medicine; School of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Amedeo Pergolini
- Cardiac Surgery and Heart Transplant Unit, Azienda Ospedaliera San Camillo Forlanini, Roma
| | - Giada Distefano
- Cardiac Surgery and Heart Transplant Unit, Azienda Ospedaliera San Camillo Forlanini, Roma
| | | | - Marina Comisso
- Cardiac Surgery and Heart Transplant Unit, Azienda Ospedaliera San Camillo Forlanini, Roma
| | - Vito Piazza
- Cardiac Surgery and Heart Transplant Unit, Azienda Ospedaliera San Camillo Forlanini, Roma
| | - Fabio Sbaraglia
- Cardiac Surgery and Heart Transplant Unit, Azienda Ospedaliera San Camillo Forlanini, Roma
| | - Francesco Musumeci
- Cardiac Surgery and Heart Transplant Unit, Azienda Ospedaliera San Camillo Forlanini, Roma
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Incremental Value of Global Longitudinal Strain to Michigan Risk Score and Pulmonary Artery Pulsatility Index in Predicting Right Ventricular Failure Following Left Ventricular Assist Devices. Heart Lung Circ 2022; 31:1110-1118. [PMID: 35491337 DOI: 10.1016/j.hlc.2022.03.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/06/2022] [Accepted: 03/31/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND The incremental utility of right ventricular (RV) strain on predicting right ventricular failure (RVF) following left ventricular assist device (LVAD) implantation, beyond clinical and haemodynamic indices, is not clear. METHODS Two hundred and forty-six (246) patients undergoing LVAD implantation, who had transthoracic echocardiograms pre and post LVAD, pulmonary artery pulsatility index (PAPI) measurements and Michigan risk score, were included. We analysed RV global longitudinal strain (GLS) using speckle tracking echocardiography. RVF following LVAD implantation was defined as the need for medical support for >14 days, or unplanned RV assist device insertion after LVAD implantation. RESULTS Mean preoperative RV-GLS was -7.8±2.8%. Among all, 27% developed postoperative RVF. A classification and regression tree analysis identified preoperative Michigan risk score, PAPI and RV-GLS as important parameters in predicting postoperative RVF. Eighty per cent (80%) of patients with PAPI <2.1 developed postoperative RVF, while only 4% of patients with PAPI >6.8 developed RVF. For patients with a PAPI of 2.1-3.2, having baseline Michigan risk score >2 points conferred an 81% probability of subsequent RVF. For patients with a PAPI of 3.3-6.8, having baseline RV-GLS of -4.9% or better conferred an 86% probability of no subsequent RVF. The sensitivity and specificity of this algorithm for predicting postoperative RVF were 67% and 93%, respectively, with an area under the curve of 0.87. CONCLUSION RV-GLS has an incremental role in predicting the development of RVF post-LVAD implantation, even after controlling for clinical and haemodynamic parameters.
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Nicoara A, Wright MC, Rosenkrans D, Patel CB, Schroder JN, Cherry AD, Hashmi NK, Pollak AL, McCartney SL, Katz J, Milano CA, Podgoreanu MV. Predictive capabilities of the European Registry for Patients with Mechanical Circulatory Support Right-Sided Heart Failure risk score after left ventricular assist device implantation. J Cardiothorac Vasc Anesth 2022; 36:3740-3746. [DOI: 10.1053/j.jvca.2022.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/09/2022] [Accepted: 06/17/2022] [Indexed: 11/11/2022]
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Bonnemain J, Del Nido PJ, Roche ET. Direct Cardiac Compression Devices to Augment Heart Biomechanics and Function. Annu Rev Biomed Eng 2022; 24:137-156. [PMID: 35395165 DOI: 10.1146/annurev-bioeng-110220-025309] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The treatment of end-stage heart failure has evolved substantially with advances in medical treatment, cardiac transplantation, and mechanical circulatory support (MCS) devices such as left ventricular assist devices and total artificial hearts. However, current MCS devices are inherently blood contacting and can lead to potential complications including pump thrombosis, hemorrhage, stroke, and hemolysis. Attempts to address these issues and avoid blood contact led to the concept of compressing the failing heart from the epicardial surface and the design of direct cardiac compression (DCC) devices. We review the fundamental concepts related to DCC, present the foundational devices and recent devices in the research and commercialization stages, and discuss the milestones required for clinical translation and adoption of this technology. Expected final online publication date for the Annual Review of Biomedical Engineering, Volume 24 is June 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Jean Bonnemain
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.,Department of Adult Intensive Care Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland;
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA;
| | - Ellen T Roche
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.,Department of Mechanical Engineering and Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA;
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Merkle-Storms J, Djordjevic I, Sabashnikov A, Eghbalzadeh K, Gkouziouta A, Fiane A, Stockman B, Montalto A, Bernhardt A, Meyns B, Netuka I, De By T, Wahlers T, Rahmanian P, Zeriouh M. Comparative analysis of LVAD patients in regard of ischaemic or idiopathic cardiomyopathy: A propensity-score analysis of EUROMACS data. Int J Artif Organs 2022; 45:284-291. [PMID: 35114824 DOI: 10.1177/03913988221075045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Despite recent advances in management of patients with advanced heart failure, mortality remains high. Aim of this study was to compare impact of different aetiology of ischaemic and idiopathic cardiomyopathy on early outcomes and long-term survival of patients after left ventricular assist device implantation. METHODS European Registry for Patients with Mechanical Circulatory Support (EUROMACS) gathers clinical data and follow-up parameters of LVAD recipients. Patients enrolled in the EUROMACS registry with primary diagnosis of either ischaemic (n = 1190) or idiopathic (n = 812) cardiomyopathy were included. Primary Endpoints were early mortality as well as long-term survival. Secondary endpoint were major postoperative adverse events, such as need for rethoracotomy. Additionally, a propensity-score matching analysis was performed for patients with ischaemic (n = 509) and idiopathic (n = 509) cardiomyopathy. RESULTS In terms of basic demographics and baseline parameters the two groups significantly differed as expected before propensity-score matching due to different aetiology of cardiomyopathy. Seven-day (52 (4.4%) versus 18 (2.2%); p = 0.009), 30-day (153 (12.9%) versus 73 (9.0%); p = 0.008) and in-hospital mortality (253 (19.7%) versus 123 (15.1%); p = 0.009) were significantly lower in the idiopathic cardiomyopathy group compared to the ischaemic cardiomyopathy group, whereas after propensity-score matching 30-day (p = 0.169) was comparable and in-hospital mortality (p = 0.051) was almost significant. Kaplan-Meier survival analysis revealed no significant difference in regard of long-term survival after propensity-score matching (Breslow-test p = 0.161 and LogRank-test p = 0.113). CONCLUSION Though patients with ischaemic and idiopathic cardiomyopathy suffer from different cardiomyopathy aetiologies, 30-day-mortality and long-term survival of both groups were similar leading to the conclusion that covariates predominately influence mortality and survival of ischaemic and idiopathic cardiomyopathies.
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Affiliation(s)
- Julia Merkle-Storms
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Cologne, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Cologne, Germany
| | | | - Arnt Fiane
- Department of Cardiothoracic Surgery, Rikshospitalet, Oslo, Norway
| | | | - Andrea Montalto
- Department of Cardiothoracic Surgery, Ospedale San Camillo, Rome, Italy
| | - Alexander Bernhardt
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Bart Meyns
- Department of Cardiothoracic Surgery, University Hospital Leuven, Leuven, Belgium
| | - Ivan Netuka
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Theo De By
- European Registry for Patients with mechanical Circulatory Support (EUROMACS), EACTS, Windsor, UK
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Cologne, Germany
| | - Parwis Rahmanian
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Cologne, Germany
| | - Mohamed Zeriouh
- Department of Cardiac Surgery, Kerckhoff Klinik, Bad Nauheim, Germany
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Bauersachs J, de Boer RA, Lindenfeld J, Bozkurt B. The year in cardiovascular medicine 2021: heart failure and cardiomyopathies. Eur Heart J 2022; 43:367-376. [PMID: 34974611 PMCID: PMC9383181 DOI: 10.1093/eurheartj/ehab887] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/27/2021] [Accepted: 11/16/2021] [Indexed: 12/22/2022] Open
Abstract
In the year 2021, the universal definition and classification of heart failure (HF) was published that defines HF as a clinical syndrome with symptoms and/or signs caused by a cardiac abnormality and corroborated by elevated natriuretic peptide levels or objective evidence of cardiogenic congestion. This definition and the classification of HF with reduced ejection fraction (HFrEF), mildly reduced, and HF with preserved ejection fraction (HFpEF) is consistent with the 2021 ESC Guidelines on HF. Among several other new recommendations, these guidelines give a Class I indication for the use of the sodium–glucose co-transporter 2 (SGLT2) inhibitors dapagliflozin and empagliflozin in HFrEF patients. As the first evidence-based treatment for HFpEF, in the EMPEROR-Preserved trial, empagliflozin reduced the composite endpoint of cardiovascular death and HF hospitalizations. Several reports in 2021 have provided novel and detailed analyses of device and medical therapy in HF, especially regarding sacubitril/valsartan, SGLT2 inhibitors, mineralocorticoid receptor antagonists, ferric carboxymaltose, soluble guanylate cyclase activators, and cardiac myosin activators. In patients hospitalized with COVID-19, acute HF and myocardial injury is quite frequent, whereas myocarditis and long-term damage to the heart are rather uncommon.
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Affiliation(s)
- Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - JoAnn Lindenfeld
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Biykem Bozkurt
- Winters Center for Heart Failure, Cardiology, Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston TX, USA
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