1
|
Patel RB, Silvestry FE, Komtebedde J, Solomon SD, Hasenfuß G, Litwin SE, Borlaug BA, Price MJ, Kawash R, Hummel SL, Cutlip DE, Leon MB, van Veldhuisen DJ, Rieth AJ, McKenzie S, Bugger H, Mazurek JA, Kapadia SR, Vanderheyden M, Ky B, Shah SJ. Atrial Shunt Device Effects on Cardiac Structure and Function in Heart Failure With Preserved Ejection Fraction: The REDUCE LAP-HF II Randomized Clinical Trial. JAMA Cardiol 2024:2817472. [PMID: 38630494 PMCID: PMC11024798 DOI: 10.1001/jamacardio.2024.0520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 02/10/2024] [Indexed: 04/19/2024]
Abstract
Importance Although the results of A Study to Evaluate the Corvia Medical Inc IASD System II to Reduce Elevated Left Atrial Pressure in Patients with Heart Failure (REDUCE LAP-HF II) trial were neutral overall, atrial shunt therapy demonstrated potential efficacy in responders (no latent pulmonary vascular disease and no cardiac rhythm management device). Post hoc analyses were conducted to evaluate the effect of shunt vs sham stratified by responder status. Objective To evaluate the effect of atrial shunt vs sham control on cardiac structure/function in the overall study and stratified by responder status. Design, Setting, and Participants This was a sham-controlled randomized clinical trial of an atrial shunt device in heart failure with preserved ejection fraction (HFpEF)/HF with mildly reduced EF (HFmrEF). Trial participants with evaluable echocardiography scans were recruited from 89 international medical centers. Data were analyzed from April 2023 to January 2024. Interventions Atrial shunt device or sham control. Main Outcome Measures Changes in echocardiographic measures from baseline to 1, 6, 12, and 24 months after index procedure. Results The modified intention-to-treat analysis of the REDUCE LAP-HF II trial included 621 randomized patients (median [IQR] age, 72.0 [66.0-77.0] years; 382 female [61.5%]; shunt arm, 309 [49.8%]; sham control arm, 312 [50.2%]). Through 24 months, 212 of 217 patients (98%) in the shunt arm with evaluable echocardiograms had patent shunts. In the overall trial population, the shunt reduced left ventricular (LV) end-diastolic volume (mean difference, -5.65 mL; P <.001), left atrial (LA) minimal volume (mean difference, -2.8 mL; P =.01), and improved LV systolic tissue Doppler velocity (mean difference, 0.69 cm/s; P <.001) and LA emptying fraction (mean difference, 1.88 percentage units; P =.02) compared with sham. Shunt treatment also increased right ventricular (RV; mean difference, 9.58 mL; P <.001) and right atrial (RA; mean difference, 9.71 mL; P <.001) volumes but had no effect on RV systolic function, pulmonary artery pressure, or RA pressure compared with sham. In the shunt arm, responders had smaller increases in RV end-diastolic volume (mean difference, 5.71 mL vs 15.18 mL; interaction P =.01), RV end-systolic volume (mean difference, 1.58 mL vs 7.89 mL; interaction P =.002), and RV/LV ratio (mean difference, 0.07 vs 0.20; interaction P <.001) and larger increases in transmitral A wave velocity (mean difference, 5.08 cm/s vs -1.97 cm/s; interaction P =.02) compared with nonresponders randomized to the shunt, suggesting greater ability to accommodate shunted blood through the pulmonary circulation enabling LA unloading. Conclusions and Relevance In this post hoc analysis of the REDUCE LAP-HF II trial, over 2 years of follow-up, atrial shunting led to reverse remodeling of left-sided chambers and increases in volume of right-sided chambers consistent with the shunt flow but no change in RV systolic function compared with sham. Changes in cardiac structure/function were more favorable in responders compared with nonresponders treated with the shunt, supporting the previously identified responder group hypothesis and mechanism, although further evaluation with longer follow-up is needed. Trial Registration ClinicalTrials.gov Identifier: NCT03088033.
Collapse
Affiliation(s)
- Ravi B. Patel
- Bluhm Cardiovascular Institute, Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Frank E. Silvestry
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia
| | | | - Scott D. Solomon
- Division of Cardiology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Gerd Hasenfuß
- Heart Centre, Georg-August Universitat, Gottigen, Germany
| | - Sheldon E. Litwin
- Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston
| | - Barry A. Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Rami Kawash
- Division of Cardiology, Ohio State Wexner Medical Center, Columbus
| | - Scott L. Hummel
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor
- VA Ann Arbor, Ann Arbor, Michigan
| | - Donald E. Cutlip
- Division of Cardiology, Beth Israel Medical Center, Boston, Massachusetts
| | | | - Dirk J. van Veldhuisen
- Department of Cardiology, University Medical Center, University of Groningen, Groningen, the Netherlands
| | - Andreas J. Rieth
- Department of Cardiology, Kerckhoff-Klinik, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Frankfurt am Main, Germany
| | - Scott McKenzie
- The Prince Charles Hospital, School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Heiko Bugger
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Jeremy A. Mazurek
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | | | | | - Bonnie Ky
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia
| | - Sanjiv J. Shah
- Bluhm Cardiovascular Institute, Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| |
Collapse
|
2
|
Moutchia J, McClelland RL, Al-Naamani N, Appleby DH, Holmes JH, Minhas J, Mazurek JA, Palevsky HI, Ventetuolo CE, Kawut SM. Pulmonary arterial hypertension treatment: an individual participant data network meta-analysis. Eur Heart J 2024:ehae049. [PMID: 38416633 DOI: 10.1093/eurheartj/ehae049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 11/20/2023] [Accepted: 01/18/2024] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND AND AIMS Effective therapies that target three main signalling pathways are approved to treat pulmonary arterial hypertension (PAH). However, there are few large patient-level studies that compare the effectiveness of these pathways. The aim of this analysis was to compare the effectiveness of the treatment pathways in PAH and to assess treatment heterogeneity. METHODS A network meta-analysis was performed using individual participant data of 6811 PAH patients from 20 Phase III randomized clinical trials of therapy for PAH that were submitted to the US Food and Drug Administration. Individual drugs were grouped by the following treatment pathways: endothelin, nitric oxide, and prostacyclin pathways. RESULTS The mean (±standard deviation) age of the sample was 49.2 (±15.4) years; 78.4% were female, 59.7% had idiopathic PAH, and 36.5% were on background PAH therapy. After covariate adjustment, targeting the endothelin + nitric oxide pathway {β: 43.7 m [95% confidence interval (CI): 32.9, 54.4]}, nitric oxide pathway [β: 29.4 m (95% CI: 22.6, 36.3)], endothelin pathway [β: 25.3 m (95% CI: 19.8, 30.8)], and prostacyclin pathway [oral/inhaled β: 19.1 m (95% CI: 14.2, 24.0), intravenous/subcutaneous β: 24.4 m (95% CI: 15.1, 33.7)] significantly increased 6 min walk distance at 12 or 16 weeks compared with placebo. Treatments also significantly reduced the likelihood of having clinical worsening events. There was significant heterogeneity of treatment effects by age, body mass index, hypertension, diabetes, and coronary artery disease. CONCLUSIONS Drugs targeting the three traditional treatment pathways significantly improve outcomes in PAH, with significant treatment heterogeneity in patients with some comorbidities. Randomized clinical trials are warranted to identify the most effective treatment strategies in a personalized approach.
Collapse
Affiliation(s)
- Jude Moutchia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robyn L McClelland
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA, USA
| | - Nadine Al-Naamani
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dina H Appleby
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - John H Holmes
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jasleen Minhas
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeremy A Mazurek
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Harold I Palevsky
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Corey E Ventetuolo
- Department of Medicine and Health Services, Policy and Practice, Brown University, Providence, RI, USA
| | - Steven M Kawut
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
3
|
Minhas J, Moutchia J, Al-Naamani N, Mazurek JA, Holmes JH, Appleby D, Smith KA, Fritz JS, Pugliese SC, Palevsky HI, Kawut SM. Electrocardiographic Abnormalities and Their Association with Outcomes in Randomized Clinical Trials of Pulmonary Arterial Hypertension. Ann Am Thorac Soc 2024. [PMID: 38241602 DOI: 10.1513/annalsats.202307-609oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 01/18/2024] [Indexed: 01/21/2024] Open
Abstract
Rationale PAH is a progressive disease with manifestations including right atrial enlargement, right ventricular dysfunction, dilation and hypertrophy. ECG is a non-invasive, inexpensive test that is routinely performed in clinical settings. Prior studies have described separate abnormal findings in ECGs of patients with PAH. However, the role of composite ECG findings reflective of right heart disease for risk stratification, clinical trial enrichment and management of patients with PAH has not been explored. Objectives i. Describe a pattern of right heart disease on ECG in patients with PAH. ii. Investigate the association of this pattern with clinical measures of disease severity and outcomes. Methods We harmonized individual participant data from 18 Phase-III randomized clinical trials of therapies for PAH (1998 - 2013) submitted to the FDA. Right heart disease (RHD) was defined as the presence of RV hypertrophy, right axis deviation, right atrial enlargement, or right bundle branch block on ECG. Random effects linear regression, multilevel ordinal regression (cumulative link model), and Cox proportional hazards models were used to assess the association of RHD by ECG with six-minute walk distance (6MWD), WHO functional class, and clinical worsening after a priori adjustment for age, sex, body mass index and PAH etiology. Effect modification of treatment and ECG abnormalities was assessed by including an interaction term. Results 4439 patients had baseline ECGs and 68% patients had evidence of RHD. RHD on ECG was associated with higher PVR (p<0.001) and higher mean PA pressures (p<0.001). Patients with RHD on ECG had 10 meters shorter 6MWD (p=0.005) and worse WHO functional class (p<0.001) at baseline. RHD on baseline ECG was associated with increased risk of clinical worsening (HR=1.42, 95%CI=1.21,1.67, p<0.001). Patients with RHD had greater treatment effect in terms of 6MWD, WHO-FC and time to clinical worsening compared to those without (p for interaction= 0.03, 0.001 and 0.03, respectively). Conclusion Right heart disease by ECG may be associated with a worse outcomes and potentially greater treatment effect. ECGs could be an inexpensive, widely available noninvasive method to enrich clinical trial populations in PAH.
Collapse
Affiliation(s)
- Jasleen Minhas
- University of Pennsylvania, 6572, Pulmonary, Allergy and Critical Care, Philadelphia, Pennsylvania, United States;
| | - Jude Moutchia
- University of Pennsylvania, 6572, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Nadine Al-Naamani
- University of Pennsylvania, 6572, Pulmonary, Allergy and Critical Care, Philadelphia, Pennsylvania, United States
| | - Jeremy A Mazurek
- University of Pennsylvania, 6572, Cardiology, Philadelphia, Pennsylvania, United States
| | - John H Holmes
- University of Pennsylvania, 6572, Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Dina Appleby
- University of Pennsylvania, 6572, Department of Biostatistics, Epidemiology, & Informatics, Philadelphia, Pennsylvania, United States
| | - Kerri A Smith
- University of Pennsylvania, 6572, Pulmonary, Allergy and Critical Care, Philadelphia, Pennsylvania, United States
| | - Jason S Fritz
- University of Pennsylvania, 6572, Pulmonary, Allergy, Critical Care, Philadelphia, Pennsylvania, United States
| | - Steven C Pugliese
- University of Pennsylvania, 6572, Pulmonary, Allergy, Critical Care, Philadelphia, Pennsylvania, United States
| | - Harold I Palevsky
- University of Pennsylvania, 6572, Pulmonary, Allergy, Critical Care, Philadelphia, Pennsylvania, United States
| | - Steven M Kawut
- University of Pennsylvania, 6572, Pulmonary, Allergy and Critical Care, Philadelphia, Pennsylvania, United States
| |
Collapse
|
4
|
Blette BS, Moutchia J, Al-Naamani N, Ventetuolo CE, Cheng C, Appleby D, Urbanowicz RJ, Fritz J, Mazurek JA, Li F, Kawut SM, Harhay MO. Is low-risk status a surrogate outcome in pulmonary arterial hypertension? An analysis of three randomised trials. Lancet Respir Med 2023; 11:873-882. [PMID: 37230098 PMCID: PMC10592525 DOI: 10.1016/s2213-2600(23)00155-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Targeting short-term improvements in multicomponent risk scores for mortality in patients with pulmonary arterial hypertension (PAH) could result in improved long-term outcomes. We aimed to determine whether PAH risk scores were adequate surrogates for clinical worsening or mortality outcomes in PAH randomised clinical trials (RCTs). METHODS We performed an individual participant data meta-analysis of RCTs selected from PAH trials provided by the US Food and Drug Administration (FDA). We calculated predicted risk using the COMPERA, COMPERA 2.0, non-invasive FPHR, REVEAL 2.0, and REVEAL Lite 2 risk scores. The primary outcome of interest was time to clinical worsening, a composite endpoint composed of any of the following events: all-cause death, hospitalisation for worsening PAH, lung transplantation, atrial septostomy, discontinuation of study treatment (or study withdrawal) for worsening PAH, initiation of parenteral prostacyclin analogue therapy, or decrease of at least 15% in 6-min walk distance from baseline, combined with either worsening of WHO functional class from baseline or the addition of an approved PAH treatment. The secondary outcome of interest was time to all-cause mortality. We assessed the surrogacy of these risk scores, parameterised as attainment of low-risk status by 16 weeks, for improvement in long-term clinical worsening and survival using mediation and meta-analysis frameworks. FINDINGS Of 28 trials received from the FDA, three RCTs (AMBITION, GRIPHON, and SERAPHIN; n=2508) had the data necessary to assess long-term surrogacy. The mean age was 49 years (SD 16), 1956 (78%) participants were women, 1704 (68%) were classified as White, and 280 (11%) were Hispanic or Latino. 1388 (55%) of 2503 participants with available data had idiopathic PAH and 776 (31%) of 2503 had PAH associated with connective tissue disease. In a mediation analysis, the proportions of treatment effects explained by attainment of low-risk status ranged only from 7% to 13%. In a meta-analysis of trial-regions, the treatment effects on low-risk status were not predictive of the treatment effects on time to clinical worsening (R2 values 0·01-0·19) nor the treatment effects on time to all-cause mortality (R2 values 0-0·2). A leave-one-out analysis suggested that the use of these risk scores as surrogates might lead to biased inferences regarding the effect of therapies on clinical outcomes in PAH RCTs. Results were similar when using absolute risk scores at 16 weeks as the potential surrogates. INTERPRETATION Multicomponent risk scores have utility for the prediction of outcomes in patients with PAH. Clinical surrogacy for long-term outcomes cannot be inferred from observational studies of outcomes. Our analyses of three PAH trials with long-term follow-up suggest that further study is necessary before using these or other scores as surrogate outcomes in PAH RCTs or clinical care. FUNDING Cardiovascular Medical Research and Education Fund, US National Institutes of Health.
Collapse
Affiliation(s)
- Bryan S Blette
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Clinical Trials Methods and Outcomes Lab, Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jude Moutchia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nadine Al-Naamani
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Corey E Ventetuolo
- Department of Health Services, Policy and Practice, Brown University, Providence, RI, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Chao Cheng
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Dina Appleby
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan J Urbanowicz
- Department of Computational Biomedicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jason Fritz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeremy A Mazurek
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Steven M Kawut
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael O Harhay
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Clinical Trials Methods and Outcomes Lab, Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| |
Collapse
|
5
|
Zhang RS, Hanff TC, Zhang Y, Genuardi MV, Peters CJ, Levin A, Molina M, McLean RC, Mazurek JA, Zamani P, Tanna MS, Wald J, Santangeli P, Atluri P, Goldberg LR, Birati EY. Chronotropic Incompetence after Heart Transplantation Is Associated with Increased Mortality and Decreased Functional Capacity. J Clin Med 2023; 12:jcm12103487. [PMID: 37240595 DOI: 10.3390/jcm12103487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/27/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023] Open
Abstract
INTRODUCTION The contribution of chronotropic incompetence to reduced exercise tolerance after a heart transplant is well known, but its role as a prognostic marker of post-transplant mortality is unclear. The aim of this study is to examine the relationship between post-transplant heart rate response (HRR) and survival. METHODS We performed a retrospective analysis of all adult heart transplant recipients at the University of Pennsylvania between the years 2000 and 2011 who underwent a cardiopulmonary exercise test (CPET) within a year of transplant. Follow-up time and survival status were observed through October 2019, using data merged from the Penn Transplant Institute. HRR was calculated by subtracting the resting HR from the peak exercise HR. The association between HRR and mortality was analyzed using Cox proportional hazard models and Kaplan-Meier analysis. The optimal cut-off point for HRR was generated by Harrell's C statistic. Patients with submaximal exercise tests were excluded, defined by a respiratory exchange ratio (RER) cut-off of 1.05. RESULTS Of 277 patients with CPETs performed within a year post-transplant, 67 were excluded for submaximal exercise. In the 210 included patients, the mean follow-up time was 10.9 years (Interquartile range (IQR) 7.8-14). Resting HR and peak HR did not significantly impact mortality after adjusting for covariates. In a multivariable linear regression analysis, each 10-beat increase in heart rate response was associated with a 1.3 mL/kg/min increase in peak VO2 and a 48 s increase in the total exercise time. Each beat/min increase in HRR was associated with a 3% reduction in the hazard of mortality (HR 0.97; 95% CI 0.96-0.99, p = 0.002). Using the optimal cut-off point generated by Harrell's C statistic, survival was significantly higher in patients with an HRR > 35 beats/min compared to those with an HRR < 35 beats/min (log rank p = 0.0012). CONCLUSION In heart transplant patients, a low HRR is associated with increased all-cause mortality and decreased exercise capacity. Additional studies are needed to validate whether targeting HRR in cardiac rehabilitation may improve outcomes.
Collapse
Affiliation(s)
- Robert S Zhang
- Division of Cardiovascular Medicine, NYU Langone Health, New York, NY 10016, USA
| | - Thomas C Hanff
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
- Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
| | - Yuhui Zhang
- Fuwai Hospital, Peking Union Medical College, Beijing 100005, China
| | - Michael V Genuardi
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
- Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
| | - Carli J Peters
- Division of Cardiovascular Medicine, NYU Langone Health, New York, NY 10016, USA
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
| | - Allison Levin
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
| | - Maria Molina
- Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
| | - Rhondalyn C McLean
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
- Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
| | - Jeremy A Mazurek
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
- Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
| | - Payman Zamani
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
- Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
| | - Monique S Tanna
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
- Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
| | - Joyce Wald
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
- Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
| | - Pasquale Santangeli
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
- Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
| | - Pavan Atluri
- Department of Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19123, USA
| | - Lee R Goldberg
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
- Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
| | - Edo Y Birati
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
- Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19123, USA
- The Lydia and Carol Kittner, Lea and Banjamin Davidai Division of Cardiovascular Medicine and Surgery, Padeh-Poriya Medical Center, Tiberias 1528001, Israel
| |
Collapse
|
6
|
Peters CJ, Zhang RS, Vidula MK, Giri J, Atluri P, Acker MA, Bermúdez CA, Levin A, Urgo K, Wald J, Mazurek JA, Hanff TC, Goldberg LR, Jagasia D, Birati EY. Durable Left Ventricular Assist Device Outflow Graft Obstructions: Clinical Characteristics and Outcomes. J Clin Med 2023; 12:jcm12062430. [PMID: 36983430 PMCID: PMC10058609 DOI: 10.3390/jcm12062430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/06/2023] [Accepted: 03/19/2023] [Indexed: 03/30/2023] Open
Abstract
PURPOSE We report on the clinical course and management of patients supported with durable implantable LVADs who developed outflow graft obstructions at a large academic center. METHODS We performed a retrospective review of patients receiving LVAD support from 2012 through 2020. Patients who developed an outflow graft obstruction diagnosed by computed tomography angiography (CTA) or angiogram were identified, and patient characteristics and outcomes were reported. RESULTS Of the 324 patients supported by LVAD at our institution, 11 patients (3.4%) were diagnosed with outflow graft obstructions. The most common presentation was low flow alarms, which was present in 10/11 patients, and the remaining patient presented with lightheadedness. Patients had minimal LDH elevation with 8/11 presenting with less than 2-fold the upper limit of normal. Transthoracic echocardiograms were not diagnostic, but CTA enabled non-invasive diagnoses in 8/11 of the patients. Three patients with extrinsic compression of the outflow graft successfully underwent endovascular stent placement, and three patients with outflow cannula kinks received supportive care. Of the five patients diagnosed with intraluminal thromboses, one received a heart transplant, one underwent an outflow graft revision, and three received supportive care due to comorbidities. CONCLUSION Outflow graft obstructions remain a rare, but serious complication. The true prevalence of this entity is likely underestimated due to the non-specific clinical presentation. CTA is a pivotal non-invasive diagnostic step. Patients with external compression were successfully treated with endovascular stenting.
Collapse
Affiliation(s)
- Carli J Peters
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Robert S Zhang
- Division of Cardiovascular Medicine, NYU Langone Health, New York, NY 10016, USA
| | - Mahesh K Vidula
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Jay Giri
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Pavan Atluri
- Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Michael A Acker
- Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Christian A Bermúdez
- Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Allison Levin
- Division of Cardiology, Duke University Medical Center, Durham, NC 27710, USA
| | - Kim Urgo
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Joyce Wald
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Jeremy A Mazurek
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Thomas C Hanff
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Lee R Goldberg
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Dinesh Jagasia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Edo Y Birati
- The Lydia and Carol Kittner, Lea and Benjamin Davidai Cardiovascular Division, Tzafon (Poriya) Medical Center, Azrieli Faculty of Medicine, Bar-Ilan University, Ramat Gan 5290002, Israel
| |
Collapse
|
7
|
Burstein DS, Rossano JW, Lindenfeld J, Schlendorf KH, Do N, Godown J, O’Connor MJ, Maeda K, Edelson JB, Lin KY, Mazurek JA, Scholl SR, Menachem JN. Association of Donors With US Public Health Service Risk Criteria and Outcomes After Adult vs Pediatric Cardiac Transplant. JAMA Cardiol 2022; 7:1121-1127. [PMID: 36129691 PMCID: PMC9494268 DOI: 10.1001/jamacardio.2022.3070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 07/18/2022] [Indexed: 12/15/2022]
Abstract
Importance The United Network for Organ Sharing (UNOS) evaluates donor risk for acute transmission of HIV, hepatitis B, or hepatitis C based on US Public Health Services (PHS)-specific criteria. However, recent data regarding use and outcomes of those donors with PHS risk criteria among pediatric and adult heart transplant recipients are lacking. Objective To compare use and outcomes of graft from donors with PHS risk criteria vs those with a standard-risk donor (SRD) in children vs adults in a contemporary cohort. Design, Setting, and Participants This cohort was a nationwide analysis of heart transplants in the US that used data from the UNOS database. Participants were children (<18 years old) and adults (≥18 years old) who received a heart transplant from January 1, 2010, to December 31, 2021. Exposures UNOS-defined donor risk status. Main Outcomes and Measures Trend analysis compared changes in PHS risk criteria use among children and adults. Patient survival was analyzed using Kaplan-Meier curves with log rank and Cox proportional hazards to compare PHS risk-criteria outcomes vs SRD-criteria outcomes in children and adult heart transplant recipients. Additional analysis was performed among adults who received a PHS-risk criteria graft that was previously declined for pediatric recipients. Results Of 5115 pediatric transplant recipients (donor without PHS risk median [IQR] age, 5 [0-13] years and donor with PHS risk median [IQR] age, 8 [0-14] years) and 30 289 adult heart transplant recipients (donor without PHS risk median [IQR] age, 56 [46-63] years and donor with PHS risk median [IQR] age, 57 [47-63] years), PHS risk criteria comprised 8% in children vs 25% in adults. PHS criteria are being increasingly used over the past decade with the proportion of recipients transplanted with PHS risk-criteria donors being approximately 3 times greater among adult recipients than children recipients. Pediatric recipients of a PHS risk-criteria donor had greater pretransplant ventilatory support, whereas adult recipients of a PHS risk-criteria donor had greater pretransplant extracorporeal membrane oxygenation use. Patient survival was similar between pediatric recipients of PHS risk-criteria grafts vs SRD-criteria grafts and slightly higher among adult recipients of PHS risk-criteria grafts vs SRD-criteria grafts. The 1778 adult recipients who received a PHS criteria-risk donor that was previously declined for pediatric recipients had similar patient survival recipients compared with SRD-criteria donors (HR, 0.92; 95% CI, 0.81-1.03; P = .18). Conclusions and Relevance In the current era, a 3-fold greater proportion of adult recipients receive a PHS risk-criteria graft compared with children despite similar posttransplant patient survival. The ongoing organ donor shortage underscores the need for consideration of PHS risk criteria where these donors remain underused.
Collapse
Affiliation(s)
| | - Joseph W. Rossano
- Cardiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - JoAnn Lindenfeld
- Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Nhue Do
- Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Justin Godown
- Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Katsuhide Maeda
- Cardiac Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Kimberly Y. Lin
- Cardiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Shelley R. Scholl
- Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | |
Collapse
|
8
|
Matura LA, Fargo JD, Boyle K, Fritz JS, Smith KA, Mazurek JA, Pinder D, Archer‐Chicko CL, Palevsky HI, Pack AI, Sommers MS, Kawut SM. Symptom phenotypes in Pulmonary Arterial Hypertension: The PAH “Symptome”. Pulm Circ 2022; 12:e12135. [PMID: 36186717 PMCID: PMC9511227 DOI: 10.1002/pul2.12135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/07/2022] [Accepted: 08/22/2022] [Indexed: 11/18/2022] Open
Abstract
Women with pulmonary arterial hypertension (PAH) experience multiple symptoms, including dyspnea, fatigue, and sleep disturbance, that impair their health‐related quality of life (HRQOL). However, we know little about phenotypic subgroups of patients with PAH with similar, concurrent, multiple symptoms. The objectives of this study were to define the “symptome” by symptom cluster phenotypes and compare characteristics such as biomarkers, cardiac structure and function (echocardiography), functional capacity (6‐min walk distance), and HRQOL between the groups. This cross‐sectional study included 60 women with PAH. Subjects completed an assessment battery: Pulmonary Arterial Hypertension Symptom Scale, Pittsburgh Sleep Quality Index, Multidimensional Dyspnea Profile, Patient‐Reported Outcomes Measurement Information System (PROMIS®) Physical Function, PROMIS® Sleep‐Related Impairment, and the emPHasis‐10. Subjects also underwent transthoracic echocardiography, phlebotomy, 6‐min walk distance, and actigraphy. The three symptoms of dyspnea, fatigue, and sleep disturbance were used to define the symptom clusters. Other PAH symptoms, plasma and serum biomarkers, cardiac structure and function (echocardiography), exercise capacity (6‐min walk distance), sleep (actigraphy), and HRQOL were compared across phenotypes. The mean age was 50 ± 18 years, 51% were non‐Hispanic white, 32% were non‐Hispanic Black and 40% had idiopathic PAH. Cluster analysis identified Mild (n = 28, 47%), Moderate (n = 20, 33%), and Severe Symptom Cluster Phenotypes (n = 12, 20%). There were no differences for age, race, or PAH etiology between the phenotypes. WHO functional class (p < 0.001), norepinephrine levels (p = 0.029), right atrial pressure (p = 0.001), physical function (p < 0.001), sleep onset latency (p = 0.040), and HRQOL (p < 0.001) all differed significantly across phenotypes. We identified three distinctive symptom cluster phenotypes (Mild, Moderate, and Severe) for women with PAH that also differed by PAH‐related symptoms, physical function, right atrial pressure, norepinephrine levels, and HRQOL. These phenotypes could suggest targeted interventions to improve symptoms and HRQOL in those most severely affected.
Collapse
Affiliation(s)
- Lea Ann Matura
- School of Nursing University of Pennsylvania Philadelphia PA
| | - Jamison D. Fargo
- Emma Eccles Jones College of Education and Human Services Utah State University Logan UT
| | | | - Jason S. Fritz
- Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Kerri A. Smith
- Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Jeremy A. Mazurek
- Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Diane Pinder
- Institutional Review Board University of Pennsylvania Philadelphia PA
| | | | | | - Allan I. Pack
- Center for Sleep and Respiratory Neurobiology University of Pennsylvania Philadelphia Pennsylvania
| | | | - Steven M. Kawut
- Perelman School of Medicine University of Pennsylvania Philadelphia PA
| |
Collapse
|
9
|
LaPatra T, Baird GL, Goodman R, Pinder D, Gaffney M, Klinger JR, Palevsky HI, Fritz J, Mullin CJ, Mazurek JA, Kawut SM, Ventetuolo CE. Reply to Helgeson et al.: Remote 6-minute-Walk Testing in Patients with Pulmonary Hypertension: Further Validation Needed? Am J Respir Crit Care Med 2022; 206:651-653. [PMID: 35608538 PMCID: PMC9716915 DOI: 10.1164/rccm.202205-0867le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Tess LaPatra
- Perelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania
| | - Grayson L. Baird
- Lifespan Hospital SystemProvidence, Rhode Island and,Brown UniversityProvidence, Rhode Island
| | - Randi Goodman
- Perelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania
| | - Diane Pinder
- Perelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania
| | | | | | - Harold I. Palevsky
- Perelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania
| | - Jason Fritz
- Perelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania
| | | | - Jeremy A. Mazurek
- Perelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania
| | - Steven M. Kawut
- Perelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania
| | | |
Collapse
|
10
|
McCarthy BE, McClelland RL, Appleby DH, Moutchia JS, Minhas JK, Min J, Mazurek JA, Smith KA, Fritz JS, Pugliese SC, Urbanowicz RJ, Holmes JH, Palevsky HI, Kawut SM, Al-Naamani N. BMI and Treatment Response in Patients With Pulmonary Arterial Hypertension. Chest 2022; 162:436-447. [PMID: 35247393 PMCID: PMC9470735 DOI: 10.1016/j.chest.2022.02.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 02/17/2022] [Accepted: 02/21/2022] [Indexed: 11/26/2022] Open
Abstract
Background Obesity is increasingly prevalent in pulmonary arterial hypertension (PAH) but is associated with improved survival, creating an “obesity paradox” in PAH. It is unknown if the improved outcomes could be attributable to obese patients deriving a greater benefit from PAH therapies. Research Question Does BMI modify treatment effectiveness in PAH? Study Design and Methods Using individual participant data, a meta-analysis was conducted of phase III, randomized, placebo-controlled trials of treatments for PAH submitted for approval to the U.S. Food and Drug Administration from 2000 to 2015. Primary outcomes were change in 6-min walk distance (6MWD) and World Health Organization (WHO) functional class. Results A total of 5,440 participants from 17 trials were included. Patients with overweight and obesity had lower baseline 6MWD and were more likely to be WHO functional class III or IV. Treatment was associated with a 27.01-m increase in 6MWD (95% CI, 21.58-32.45; P < .001) and lower odds of worse WHO functional class (OR, 0.58; 95% CI, 0.48-0.70; P < .001). For every 1 kg/m2 increase in BMI, 6MWD was reduced by 0.66 m (P = .07); there was no significant effect modification of treatment response in 6MWD according to BMI (P for interaction = .34). Higher BMI was not associated with odds of WHO functional class at end of follow-up; however, higher BMI attenuated the treatment response such that every 1 kg/m2 increase in BMI increased odds of worse WHO functional class by 3% (OR, 1.03; P for interaction = .06). Interpretation Patients with overweight and obesity had lower baseline 6MWD and worse WHO functional class than patients with normal weight with PAH. Higher BMI did not modify the treatment response for change in 6MWD, but it attenuated the treatment response for WHO functional class. PAH trials should include participants representative of all weight groups to allow for assessment of treatment heterogeneity and mechanisms.
Collapse
|
11
|
Mercurio V, Hassan HJ, Naranjo M, Cuomo A, Mazurek JA, Forfia PR, Balasubramanian A, Simpson CE, Damico RL, Kolb TM, Mathai SC, Hsu S, Mukherjee M, Hassoun PM. Risk Stratification of Patients with Pulmonary Arterial Hypertension: The Role of Echocardiography. J Clin Med 2022; 11:4034. [PMID: 35887800 PMCID: PMC9323074 DOI: 10.3390/jcm11144034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 06/28/2022] [Accepted: 07/09/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Given the morbidity and mortality associated with pulmonary arterial hypertension (PAH), risk stratification approaches that guide therapeutic management have been previously employed. However, most patients remain in the intermediate-risk category despite initial therapy. Herein, we sought to determine whether echocardiographic parameters could improve the risk stratification of intermediate-risk patients. Methods: Prevalent PAH patients previously enrolled in observational studies at 3 pulmonary hypertension centers were included in this study. A validated PAH risk stratification approach was used to stratify patients into low-, intermediate-, and high-risk groups. Right ventricular echocardiographic parameters were used to further stratify intermediate-risk patients into intermediate-low- and intermediate-high-risk groups based on transplant-free survival. Results: From a total of 146 patients included in our study, 38 patients died over a median follow-up of 2.5 years. Patients with intermediate-/high-risk had worse echocardiographic parameters. Tricuspid annular plane systolic excursion (TAPSE) and the degree of tricuspid regurgitation (TR) were highly associated with survival (p < 0.01, p = 0.04, respectively) and were subsequently used to further stratify intermediate-risk patients. Among intermediate-risk patients, survival was worse for patients with TAPSE < 19 mm compared to those with TAPSE ≥ 19 mm (estimated one-year survival 74% vs. 96%, p < 0.01) and for patients with moderate/severe TR compared to those with no/trace/mild TR (estimated one-year survival 70% vs. 93%, p < 0.01). Furthermore, among intermediate-risk patients, those with both TAPSE < 19 mm and moderate/severe TR had an estimated one-year survival (56%) similar to that of high-risk patients (56%), and those with both TAPSE ≥ 19 mm and no/trace/mild TR had an estimated one-year survival (97%) similar to that of low-risk patients (95%). Conclusions: Echocardiography, a routinely performed, non-invasive imaging modality, plays a pivotal role in discriminating distinct survival phenotypes among prevalent intermediate-risk PAH patients using TAPSE and degree of TR. This can potentially help guide subsequent therapy.
Collapse
Affiliation(s)
- Valentina Mercurio
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (H.J.H.); (M.N.); (A.B.); (C.E.S.); (R.L.D.); (T.M.K.); (S.C.M.)
- Department of Translational Medical Sciences, Federico II University, 80131 Naples, Italy;
| | - Hussein J. Hassan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (H.J.H.); (M.N.); (A.B.); (C.E.S.); (R.L.D.); (T.M.K.); (S.C.M.)
| | - Mario Naranjo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (H.J.H.); (M.N.); (A.B.); (C.E.S.); (R.L.D.); (T.M.K.); (S.C.M.)
| | - Alessandra Cuomo
- Department of Translational Medical Sciences, Federico II University, 80131 Naples, Italy;
| | - Jeremy A. Mazurek
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Paul R. Forfia
- Pulmonary Hypertension, Right Heart Failure and Pulmonary Thromboendarterectomy Program, Temple University Hospital, Philadelphia, PA 19140, USA;
| | - Aparna Balasubramanian
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (H.J.H.); (M.N.); (A.B.); (C.E.S.); (R.L.D.); (T.M.K.); (S.C.M.)
| | - Catherine E. Simpson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (H.J.H.); (M.N.); (A.B.); (C.E.S.); (R.L.D.); (T.M.K.); (S.C.M.)
| | - Rachel L. Damico
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (H.J.H.); (M.N.); (A.B.); (C.E.S.); (R.L.D.); (T.M.K.); (S.C.M.)
| | - Todd M. Kolb
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (H.J.H.); (M.N.); (A.B.); (C.E.S.); (R.L.D.); (T.M.K.); (S.C.M.)
| | - Stephen C. Mathai
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (H.J.H.); (M.N.); (A.B.); (C.E.S.); (R.L.D.); (T.M.K.); (S.C.M.)
| | - Steven Hsu
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (S.H.); (M.M.)
| | - Monica Mukherjee
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (S.H.); (M.M.)
| | - Paul M. Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (H.J.H.); (M.N.); (A.B.); (C.E.S.); (R.L.D.); (T.M.K.); (S.C.M.)
| |
Collapse
|
12
|
Peters CJ, Hanff TC, Genuardi MV, Zhang R, Domenico C, Atluri P, Mazurek JA, Urgo K, Wald J, Tanna MS, Shore S, Acker MA, Goldberg LR, Margulies KB, Birati EY. Safety and Effectiveness of Intravenous Iron Therapy in Patients Supported by Durable Left Ventricular Assist Devices. J Clin Med 2022; 11:jcm11133900. [PMID: 35807184 PMCID: PMC9267846 DOI: 10.3390/jcm11133900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/21/2022] [Accepted: 07/01/2022] [Indexed: 12/04/2022] Open
Abstract
Aims: While it is common practice to use intravenous (IV) iron in patients with left ventricular assist devices (LVADs) and iron deficiency, there is insufficient evidence regarding outcomes in this patient population. We evaluated the safety and effectiveness of IV iron therapy in patients supported by LVADs with iron deficiency. Methods: We performed a retrospective analysis of iron deficient patients on continuous LVAD support at a large academic center between 2008 and 2019. Patients were divided into two cohorts based on IV iron sucrose treatment. The primary endpoint was hemoglobin at 12 weeks. Secondary endpoints were mean corpuscular volume (MCV) and New York Heart Association (NYHA) class at 12 weeks. Safety endpoints included hospitalization, infection, pump thrombosis, arrhythmia, and gastrointestinal bleed. Models were weighted by the inverse probability of receiving IV iron using a propensity score, and endpoints were adjusted for their corresponding baseline values. Results: Among 213 patients, 70 patients received IV iron and 143 patients did not. Hemoglobin at 12 weeks was significantly greater among those treated (intergroup difference: 0.6 g/dL; 95% CI, 0.1 to 1.1; p = 0.01), while MCV was similar in both groups (intergroup difference: 0.7 μm3; 95% CI, −1.3 to 2.7; p = 0.50). NYHA class distribution at 12 weeks was significantly different (odds ratio for improvement: 2.84; 95% CI, 1.42 to 4.68; p = 0.003). The hazards of adverse events in each group were similar. Conclusions: In patients with LVADs and iron deficiency, treatment with IV iron sucrose was safe and associated with improvements in functional status and hemoglobin.
Collapse
Affiliation(s)
- Carli J. Peters
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.J.P.); (T.C.H.); (M.V.G.); (R.Z.); (J.A.M.); (J.W.); (M.S.T.); (L.R.G.); (K.B.M.)
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Thomas C. Hanff
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.J.P.); (T.C.H.); (M.V.G.); (R.Z.); (J.A.M.); (J.W.); (M.S.T.); (L.R.G.); (K.B.M.)
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Michael V. Genuardi
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.J.P.); (T.C.H.); (M.V.G.); (R.Z.); (J.A.M.); (J.W.); (M.S.T.); (L.R.G.); (K.B.M.)
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Robert Zhang
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.J.P.); (T.C.H.); (M.V.G.); (R.Z.); (J.A.M.); (J.W.); (M.S.T.); (L.R.G.); (K.B.M.)
| | - Christopher Domenico
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
- Department of Pharmacy, Hospital of The University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Pavan Atluri
- Department of Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (P.A.); (K.U.); (M.A.A.)
| | - Jeremy A. Mazurek
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.J.P.); (T.C.H.); (M.V.G.); (R.Z.); (J.A.M.); (J.W.); (M.S.T.); (L.R.G.); (K.B.M.)
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Kim Urgo
- Department of Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (P.A.); (K.U.); (M.A.A.)
| | - Joyce Wald
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.J.P.); (T.C.H.); (M.V.G.); (R.Z.); (J.A.M.); (J.W.); (M.S.T.); (L.R.G.); (K.B.M.)
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Monique S. Tanna
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.J.P.); (T.C.H.); (M.V.G.); (R.Z.); (J.A.M.); (J.W.); (M.S.T.); (L.R.G.); (K.B.M.)
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Supriya Shore
- Cardiovascular Division, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Michael A. Acker
- Department of Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (P.A.); (K.U.); (M.A.A.)
| | - Lee R. Goldberg
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.J.P.); (T.C.H.); (M.V.G.); (R.Z.); (J.A.M.); (J.W.); (M.S.T.); (L.R.G.); (K.B.M.)
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
- Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kenneth B. Margulies
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.J.P.); (T.C.H.); (M.V.G.); (R.Z.); (J.A.M.); (J.W.); (M.S.T.); (L.R.G.); (K.B.M.)
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Edo Y. Birati
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.J.P.); (T.C.H.); (M.V.G.); (R.Z.); (J.A.M.); (J.W.); (M.S.T.); (L.R.G.); (K.B.M.)
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
- Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA 19104, USA
- The Lydia and Carol Kittner, Lea and Banjamin Davidai Division of Cardiovascular Medicine and Surgery, Padeh-Poriya Medical Center, Azrieli Faculty of Medicine, Bar-Ilan University, Ramat Gan 5290002, Israel
- Correspondence: ; Tel.: +972-4-6652648; Fax: +972-4-6652678
| |
Collapse
|
13
|
Zhang RS, Hanff TC, Peters CJ, Evans PT, Marble J, Rame JE, Atluri P, Urgo K, Tanna MS, Mazurek JA, Acker MA, Cevasco M, Birati EY, Wald JW. Left Ventricular Assist Device as a Bridge to Recovery: Single Center Experience of Successful Device Explantation. ASAIO J 2022; 68:822-828. [PMID: 34560718 DOI: 10.1097/mat.0000000000001574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Continuous-flow left ventricular assist devices (CF-LVAD) have been shown to enhance reverse remodeling and myocardial recovery in certain patients allowing for device removal. We sought to analyze the characteristics and describe outcomes of patients who underwent CF-LVAD explantation at a large academic center. We retrospectively identified all patients who underwent CF-LVAD explants due to recovery from 2006 to 2019. Patient baseline characteristics and data on pre- and postexplant evaluation were collected and analyzed. Of 421 patients who underwent CF-LVAD implantation, 13 underwent explantation (3.1%). Twelve HeartMate II and one HeartWare LVAD were explanted. All patients had nonischemic cardiomyopathy. Median time from heart failure diagnosis to LVAD implant was 12 months (interquartile range [IQR], 2-44) and the median time supported on LVAD was 22 months (IQR, 11-28). Two patients died within 30 days of explant. Three additional patients died during the follow-up period and all were noted to be nonadherent to medical therapy. After a mean follow-up duration of 5 years, overall survival was 52%. Mean pre-explant ejection fraction was 49%, which decreased at most recent follow-up to 32%. Mean pre-explant left ventricular internal diameter in diastole (LVIDD) was 4.37 cm and increased to 5.52 cm at most recent follow-up. Continuous-flow left ventricular assist device explantation is feasible and safe in select patients.
Collapse
Affiliation(s)
- Robert S Zhang
- From the Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas C Hanff
- From the Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carli J Peters
- From the Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter T Evans
- From the Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Judy Marble
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Eduardo Rame
- Division of Cardiovascular Medicine, Jefferson Hospital University, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kimberly Urgo
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Monique S Tanna
- From the Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy A Mazurek
- From the Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael A Acker
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edo Y Birati
- From the Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce W Wald
- From the Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
14
|
Wang TS, Cevasco M, Birati EY, Mazurek JA. Predicting, Recognizing, and Treating Right Heart Failure in Patients Undergoing Durable LVAD Therapy. J Clin Med 2022; 11:jcm11112984. [PMID: 35683372 PMCID: PMC9181012 DOI: 10.3390/jcm11112984] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 12/04/2022] Open
Abstract
Despite advancing technology, right heart failure after left ventricular assist device implantation remains a significant source of morbidity and mortality. With the UNOS allocation policy change, a larger proportion of patients proceeding to LVAD are destination therapy and consist of an overall sicker population. Thus, a comprehensive understanding of right heart failure is critical for ensuring the ongoing success of durable LVADs. The purpose of this review is to describe the effect of LVAD implantation on right heart function, review the diagnostic and predictive criteria related to right heart failure, and discuss the current evidence for management and treatment of post-LVAD right heart failure.
Collapse
Affiliation(s)
- Teresa S. Wang
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
- Correspondence: ; Tel.: +1-267-624-7276
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Edo Y. Birati
- Division of Cardiovascular Medicine, Padeh-Poriya Medical Center, Bar-Ilan University, Ramat Gan 5290002, Israel;
| | - Jeremy A. Mazurek
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| |
Collapse
|
15
|
Borlaug BA, Blair J, Bergmann MW, Bugger H, Burkhoff D, Bruch L, Celermajer DS, Claggett B, Cleland JGF, Cutlip DE, Dauber I, Eicher JC, Gao Q, Gorter TM, Gustafsson F, Hayward C, van der Heyden J, Hasenfuß G, Hummel SL, Kaye DM, Komtebedde J, Massaro JM, Mazurek JA, McKenzie S, Mehta SR, Petrie MC, Post MC, Nair A, Rieth A, Silvestry FE, Solomon SD, Trochu JN, Van Veldhuisen DJ, Westenfeld R, Leon MB, Shah SJ. Latent Pulmonary Vascular Disease May Alter the Response to Therapeutic Atrial Shunt Device in Heart Failure. Circulation 2022; 145:1592-1604. [PMID: 35354306 PMCID: PMC9133195 DOI: 10.1161/circulationaha.122.059486] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND In REDUCE LAP-HF II (A Study to Evaluate the Corvia Medical, Inc IASD System II to Reduce Elevated Left Atrial Pressure in Patients With Heart Failure), implantation of an atrial shunt device did not provide overall clinical benefit for patients with heart failure with preserved or mildly reduced ejection fraction. However, prespecified analyses identified differences in response in subgroups defined by pulmonary artery systolic pressure during submaximal exercise, right atrial volume, and sex. Shunt implantation reduces left atrial pressures but increases pulmonary blood flow, which may be poorly tolerated in patients with pulmonary vascular disease (PVD). On the basis of these results, we hypothesized that patients with latent PVD, defined as elevated pulmonary vascular resistance during exercise, might be harmed by shunt implantation, and conversely that patients without PVD might benefit. METHODS REDUCE LAP-HF II enrolled 626 patients with heart failure, ejection fraction ≥40%, exercise pulmonary capillary wedge pressure ≥25 mm Hg, and resting pulmonary vascular resistance <3.5 Wood units who were randomized 1:1 to atrial shunt device or sham control. The primary outcome-a hierarchical composite of cardiovascular death, nonfatal ischemic stroke, recurrent HF events, and change in health status-was analyzed using the win ratio. Latent PVD was defined as pulmonary vascular resistance ≥1.74 Wood units (highest tertile) at peak exercise, measured before randomization. RESULTS Compared with patients without PVD (n=382), those with latent PVD (n=188) were older, had more atrial fibrillation and right heart dysfunction, and were more likely to have elevated left atrial pressure at rest. Shunt treatment was associated with worse outcomes in patients with PVD (win ratio, 0.60 [95% CI, 0.42, 0.86]; P=0.005) and signal of clinical benefit in patients without PVD (win ratio, 1.31 [95% CI, 1.02, 1.68]; P=0.038). Patients with larger right atrial volumes and men had worse outcomes with the device and both groups were more likely to have pacemakers, heart failure with mildly reduced ejection fraction, and increased left atrial volume. For patients without latent PVD or pacemaker (n=313; 50% of randomized patients), shunt treatment resulted in more robust signal of clinical benefit (win ratio, 1.51 [95% CI, 1.14, 2.00]; P=0.004). CONCLUSIONS In patients with heart failure with preserved or mildly reduced ejection fraction, the presence of latent PVD uncovered by invasive hemodynamic exercise testing identifies patients who may worsen with atrial shunt therapy, whereas those without latent PVD may benefit.
Collapse
Affiliation(s)
- Barry A. Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Dan Burkhoff
- Cardiovascular Research Foundation, New York NY, USA
| | | | | | | | - John GF Cleland
- Robertson Centre for Biostatistics and Glasgow Clinical Trials Unit, Institute of Health and Wellbeing, Glasgow, and National Heart & Lung Institute, Imperial College London, United Kingdom
| | | | - Ira Dauber
- South Denver Cardiology Associates/Centura Health. Denver, CO, USA
| | | | - Qi Gao
- Baim Clinical Research Institute, Boston, MA
| | - Thomas M. Gorter
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Finn Gustafsson
- Rigshospitalet, University ofCopenhagen, Copenhagen, Denmark
| | | | | | - Gerd Hasenfuß
- Heart Center, University Medical Center, Göttingen, Germany
| | - Scott L Hummel
- University of Michigan, Ann Harbor, MI and VA Ann Arbor Health System, Ann Arbor, MI
| | | | | | | | | | | | - Shamir R. Mehta
- McMaster University and Hamilton Health Sciences, Hamilton, Canada
| | | | - Marco C. Post
- Departments of Cardiology, St. Antonius Hospital Nieuwegein and University Medical Center Utrecht, The Netherlands
| | | | - Andreas Rieth
- Kerckhoff Heart and Thoraxcenter, Bad Nauheim, Germany
| | | | | | - Jean-Noël Trochu
- Nantes Université, CHU Nantes, CNRS, INSERM, l’institut du thorax, F-44000 Nantes, France
| | - Dirk J. Van Veldhuisen
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology, and Vascular Medicine Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | | | - Sanjiv J. Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | | |
Collapse
|
16
|
Liang LW, Jamil A, Mazurek JA, Urgo KA, Wald J, Birati EY, Han Y. Right Ventricular Global Longitudinal Strain as a Predictor of Acute and Early Right Heart Failure Post Left Ventricular Assist Device Implantation. ASAIO J 2022; 68:333-339. [PMID: 34310094 PMCID: PMC8578577 DOI: 10.1097/mat.0000000000001467] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Early right heart failure (RHF) occurs in up to 40% of patients following left ventricular assist device (LVAD) implantation and is associated with increased morbidity and mortality. The most recent report from the Mechanical Circulatory Support-Academic Research Consortium (MCS-ARC) working group subdivides early RHF into early acute RHF and early postimplant RHF. We sought to determine the effectiveness of right ventricular (RV) longitudinal strain (LS) in predicting RHF according to the new MCS-ARC definition. We retrospectively analyzed clinical and echocardiographic data of patients who underwent LVAD implantation between 2015 and 2018. RVLS in the 4-chamber (4ch), RV outflow tract, and subcostal views were measured on pre-LVAD echocardiograms. Fifty-five patients were included in this study. Six patients (11%) suffered early acute RHF, requiring concomitant RVAD implantation intraoperatively. Twenty-two patients (40%) had postimplant RHF. RVLS was significantly reduced in patients who developed early acute and postimplant RHF. At a cutoff of -9.7%, 4ch RVLS had a sensitivity of 88.9% and a specificity of 77.8% for predicting RHF and area under the receiver operating characteristic curve of 0.86 (95% confidence interval 0.76-0.97). Echocardiographic RV strain outperformed more invasive hemodynamic measures and clinical parameters in predicting RHF.
Collapse
Affiliation(s)
- Lusha W Liang
- From the Cardiovascular Division, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Alisha Jamil
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy A Mazurek
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kimberly A Urgo
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce Wald
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edo Y Birati
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yuchi Han
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
17
|
Edelson JB, Edwards JJ, Katcoff H, Mondal A, Chen F, Reza N, Hanff TC, Griffis H, Mazurek JA, Wald J, Burstein DS, Atluri P, O'Connor MJ, Goldberg LR, Zamani P, Groeneveld PW, Rossano JW, Lin KY, Birati EY. Novel Risk Model to Predict Emergency Department Associated Mortality for Patients Supported With a Ventricular Assist Device: The Emergency Department-Ventricular Assist Device Risk Score. J Am Heart Assoc 2022; 11:e020942. [PMID: 35023355 PMCID: PMC9238533 DOI: 10.1161/jaha.121.020942] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The past decade has seen tremendous growth in patients with ambulatory ventricular assist devices. We sought to identify patients that present to the emergency department (ED) at the highest risk of death. Methods and Results This retrospective analysis of ED encounters from the Nationwide Emergency Department Sample includes 2010 to 2017. Using a random sampling of patient encounters, 80% were assigned to development and 20% to validation cohorts. A risk model was derived from independent predictors of mortality. Each patient encounter was assigned to 1 of 3 groups based on risk score. A total of 44 042 ED ventricular assist device patient encounters were included. The majority of patients were male (73.6%), <65 years old (60.1%), and 29% presented with bleeding, stroke, or device complication. Independent predictors of mortality during the ED visit or subsequent admission included age ≥65 years (odds ratio [OR], 1.8; 95% CI, 1.3-4.6), primary diagnoses (stroke [OR, 19.4; 95% CI, 13.1-28.8], device complication [OR, 10.1; 95% CI, 6.5-16.7], cardiac [OR, 4.0; 95% CI, 2.7-6.1], infection [OR, 5.8; 95% CI, 3.5-8.9]), and blood transfusion (OR, 2.6; 95% CI, 1.8-4.0), whereas history of hypertension was protective (OR, 0.69; 95% CI, 0.5-0.9). The risk score predicted mortality areas under the curve of 0.78 and 0.71 for development and validation. Encounters in the highest risk score strata had a 16-fold higher mortality compared with the lowest risk group (15.8% versus 1.0%). Conclusions We present a novel risk score and its validation for predicting mortality of patients with ED ventricular assist devices, a high-risk, and growing, population.
Collapse
Affiliation(s)
- Jonathan B Edelson
- Division of Cardiology Cardiac Center, the Children's Hospital of PhiladelphiaPerelman School of MedicineUniversity of Pennsylvania Philadelphia PA.,Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of Pennsylvania Philadelphia PA.,Leonard Davis Institute for Healthcare EconomicsUniversity of Pennsylvania Philadelphia PA
| | - Jonathan J Edwards
- Division of Cardiology Cardiac Center, the Children's Hospital of PhiladelphiaPerelman School of MedicineUniversity of Pennsylvania Philadelphia PA
| | - Hannah Katcoff
- Data Science and Biostatistics Unit Department of Biomedical and Health Informatics The Children's Hospital of Philadelphia Philadelphia PA
| | - Antara Mondal
- Data Science and Biostatistics Unit Department of Biomedical and Health Informatics The Children's Hospital of Philadelphia Philadelphia PA
| | - Feiyan Chen
- Data Science and Biostatistics Unit Department of Biomedical and Health Informatics The Children's Hospital of Philadelphia Philadelphia PA
| | - Nosheen Reza
- Cardiovascular Division Department of Medicine Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Thomas C Hanff
- Cardiovascular Division Department of Medicine Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Heather Griffis
- Leonard Davis Institute for Healthcare EconomicsUniversity of Pennsylvania Philadelphia PA
| | - Jeremy A Mazurek
- Cardiovascular Division Department of Medicine Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Joyce Wald
- Cardiovascular Division Department of Medicine Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Danielle S Burstein
- Division of Cardiology Cardiac Center, the Children's Hospital of PhiladelphiaPerelman School of MedicineUniversity of Pennsylvania Philadelphia PA
| | - Pavan Atluri
- Cardiothoracic Surgery Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Matthew J O'Connor
- Division of Cardiology Cardiac Center, the Children's Hospital of PhiladelphiaPerelman School of MedicineUniversity of Pennsylvania Philadelphia PA
| | - Lee R Goldberg
- Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of Pennsylvania Philadelphia PA.,Cardiovascular Division Department of Medicine Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Payman Zamani
- Cardiovascular Division Department of Medicine Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Peter W Groeneveld
- Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of Pennsylvania Philadelphia PA.,General Internal Medicine Division Department of Medicine Perelman School of MedicineUniversity of Pennsylvania Philadelphia PA
| | - Joseph W Rossano
- Division of Cardiology Cardiac Center, the Children's Hospital of PhiladelphiaPerelman School of MedicineUniversity of Pennsylvania Philadelphia PA.,Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of Pennsylvania Philadelphia PA
| | - Kimberly Y Lin
- Division of Cardiology Cardiac Center, the Children's Hospital of PhiladelphiaPerelman School of MedicineUniversity of Pennsylvania Philadelphia PA
| | - Edo Y Birati
- Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of Pennsylvania Philadelphia PA.,Cardiothoracic Surgery Perelman School of Medicine University of Pennsylvania Philadelphia PA.,The Lydia and Carol Kittner, Lea and Benjamin Davidai Division of Cardiovascular Medicine and Surgery Padeh-Poriya Medical CenterBar Ilan University Israel
| |
Collapse
|
18
|
LaPatra T, Baird GL, Goodman R, Pinder D, Gaffney M, Klinger JR, Palevsky HI, Fritz J, Mullin CJ, Mazurek JA, Kawut SM, Ventetuolo CE. Remote Six-Minute Walk Testing in Patients with Pulmonary Hypertension: A Pilot Study. Am J Respir Crit Care Med 2022; 205:851-854. [PMID: 35015981 DOI: 10.1164/rccm.202110-2421le] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Tess LaPatra
- University of Pennsylvania Perelman School of Medicine, 14640, Department of Medicine, Philadelphia, Pennsylvania, United States
| | - Grayson L Baird
- Lifespan Hospital System, Biostatistics Core, Providence, Rhode Island, United States
| | - Randi Goodman
- University of Pennsylvania, 6572, Pulmonary, Allergy, Critical Care, Philadelphia, Pennsylvania, United States
| | - Diane Pinder
- University of Pennsylvania, 6572, Philadelphia, Pennsylvania, United States
| | - Maeve Gaffney
- Columbia University, 5798, New York, New York, United States
| | - James R Klinger
- Rhode Island Hospital, Pulm/CC, Providence, Rhode Island, United States.,Brown Univeristy, Providence, Rhode Island, United States
| | - Harold I Palevsky
- Perelman School of Medicine, Medicine, Philadelphia, Pennsylvania, United States
| | - Jason Fritz
- University of Pennsylvania, Pulmonary, Allergy and Critical Care, 19104, Pennsylvania, United States
| | - Christopher J Mullin
- Brown University Warren Alpert Medical School, 12321, Pulmonary, Critical Care, and Sleep Medicine, Providence, Rhode Island, United States
| | - Jeremy A Mazurek
- University of Pennsylvania, 6572, Philadelphia, Pennsylvania, United States
| | - Steven M Kawut
- University of Pennsylvania Perelman School of Medicine, 14640, Medicine , Philadelphia, Pennsylvania, United States
| | | |
Collapse
|
19
|
Goodman R, Chirinos JA, Ky B, Mazurek JA, Smith KA, Palevsky HI, Fritz JS, Pugliese SC, Kawut SM, Al-Naamani N. Systemic arterial properties in pulmonary hypertension. Pulm Circ 2021; 11:20458940211055684. [PMID: 34804490 PMCID: PMC8597072 DOI: 10.1177/20458940211055684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Randi Goodman
- Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Julio A Chirinos
- Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Bonnie Ky
- Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeremy A Mazurek
- Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kerri Akaya Smith
- Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Harold I Palevsky
- Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Jason S Fritz
- Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven C Pugliese
- Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven M Kawut
- Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Nadine Al-Naamani
- Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
20
|
Edwards JJ, Edelson JB, Katcoff H, Mondal A, Lefkowitz D, Reza N, Hanff TC, Griffis H, Mazurek JA, Wald J, Owens AT, Wittlieb-Weber CA, Burstein DS, Atluri P, O'Connor MJ, Goldberg LR, Zamani P, Groeneveld PW, Rossano JW, Lin KY, Birati EY. Mental health disorders and emergency resource use and outcomes in ventricular assist device supported patients. Am Heart J 2021; 240:11-15. [PMID: 34089695 PMCID: PMC8484029 DOI: 10.1016/j.ahj.2021.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 05/28/2021] [Indexed: 11/20/2022]
Abstract
There are limited data describing the prevalence of mental health disorders (MHDOs) in patients with ventricular assist devices (VADs), or associations between MHDOs and resource use or outcomes. We used the Nationwide Emergency Department Sample administrative database to analyze 44,041 ED encounters for VAD-supported adults from 2010 to 2017, to assess the relationship between MHDOs and outcomes in this population. MHDO diagnoses were present for 23% of encounters, and were associated with higher charges and rates of admission, but lower mortality.
Collapse
Affiliation(s)
- Jonathan J Edwards
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA.
| | - Jonathan B Edelson
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA; Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Pennsylvania, PA; Leonard Davis Institute for Healthcare Economics, University of Pennsylvania, Pennsylvania , PA
| | - Hannah Katcoff
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit the Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Antara Mondal
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit the Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Debra Lefkowitz
- Department of Child and Adolescent Psychiatry and avioral Sciences, the Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Nosheen Reza
- Department of Medicine, Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA
| | - Thomas C Hanff
- Department of Medicine, Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA
| | - Heather Griffis
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit the Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Jeremy A Mazurek
- Department of Medicine, Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA
| | - Joyce Wald
- Department of Medicine, Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA
| | - Anjali T Owens
- Department of Medicine, Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA
| | - Carol A Wittlieb-Weber
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA
| | - Danielle S Burstein
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA
| | - Pavan Atluri
- Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania , PA
| | - Matthew J O'Connor
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA
| | - Lee R Goldberg
- Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Pennsylvania, PA; Department of Medicine, General Internal Medicine Division, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA
| | - Payman Zamani
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit the Children's Hospital of Philadelphia, Pennsylvania, PA
| | - Peter W Groeneveld
- Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Pennsylvania, PA; Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania , PA
| | - Joseph W Rossano
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA; Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Pennsylvania, PA
| | - Kimberly Y Lin
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA
| | - Edo Y Birati
- Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Pennsylvania, PA; Department of Medicine, General Internal Medicine Division, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA; Cardiovascular Division, Poriya Medical Center, Bar-Ilan University, Israel
| |
Collapse
|
21
|
Bermudez CA, Crespo MM, Shlobin OA, Cantu E, Mazurek JA, Levine D, Gutsche J, Kanwar M, Dellgren G, Bush EL, Heresi GA, Cypel M, Hadler R, Kolatis N, Franco V, Benvenuto L, Mooney J, Pipeling M, King C, Mannem H, Raman S, Knoop C, Douglas A, Mercier O. ISHLT consensus document on lung transplantation in patients with connective tissue disease: Part II: Cardiac, surgical, perioperative, operative, and post-operative challenges and management statements. J Heart Lung Transplant 2021; 40:1267-1278. [PMID: 34404570 DOI: 10.1016/j.healun.2021.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 01/09/2023] Open
Abstract
Patients with connective tissue disease (CTD) present unique surgical, perioperative, operative, and postoperative challenges related to the often underlying severe pulmonary hypertension and right ventricular dysfunction. The International Society for Heart and Lung Transplantation-supported consensus document on lung transplantation in patients with CTD standardization addresses the surgical challenges and relevant cardiac involvement in the perioperative, operative, and postoperative management in patients with CTD.
Collapse
Affiliation(s)
- Christian A Bermudez
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Maria M Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Oksana A Shlobin
- Department of Pulmonary and Critical Care Medicine, Inova Fairfax Hospital, Falls Church, Virginia
| | - Edward Cantu
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy A Mazurek
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Deborah Levine
- Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center San Antonio, Texas
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Göran Dellgren
- Department of Cardiothoracic Surgery and Transplant Institute, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Errol L Bush
- Division of Thoracic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Marcello Cypel
- Division of Thoracic Surgery, Toronto General Hospital UHN, Toronto, Ontario, Canada
| | - Rachel Hadler
- Division of Critical Care, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Nicholas Kolatis
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco Medical Center, San Francisco, California
| | - Veronica Franco
- Department of Cardiology, The Ohio State university Wexner Medical Center, Columbus, Ohio
| | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical center, New York, New York
| | - Joshua Mooney
- Division of Pulmonary and Critical Care Medicine, Stanford Health Care, Palo Alto, California
| | - Matthew Pipeling
- Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
| | - Christopher King
- Department of Pulmonary and Critical Care Medicine, Inova Fairfax Hospital, Falls Church, Virginia
| | - Hannah Mannem
- Division of Pulmonary and Critical Care Medicine, University of Virginia, Charlottesville, Virginia
| | - Sanjeev Raman
- Division of Pulmonary Medicine, University of Utah, Salt Lake City, Utah
| | | | - Aaron Douglas
- Division of Anesthesiology and Critical Care, Cleveland Clinic, Cleveland, Ohio
| | - Olaf Mercier
- Department of Thoracic Surgery, Université Paris-Saclay, Marie Lannelongue Hospital, Le Plessis Robinson, France
| |
Collapse
|
22
|
Clark DE, Byrne RD, Mazurek JA, Opotowsky AR, Schlendorf KH, Xu M, Zalawadiya S, Menachem JN. Sizing heart transplant donors in adults with congenital heart disease. J Thorac Cardiovasc Surg 2021; 162:422-428.e1. [DOI: 10.1016/j.jtcvs.2020.01.099] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/15/2020] [Accepted: 01/20/2020] [Indexed: 02/08/2023]
|
23
|
Genuardi MV, Moss N, Najjar SS, Houston BA, Shore S, Vorovich E, Atluri P, Molina M, Chambers S, Sharkoski T, Hsich E, Estep JD, Owens AT, Alexander KM, Chaudhry SP, Garcia-Cortes R, Molina E, Rodrigo M, Wald MDJ, Margulies KB, Hanff TC, Zimmer R, Kilic A, Mclean R, Vidula H, Dodd K, Blumberg EA, Mazurek JA, Goldberg LR, Alvarez-Garcia J, Mancini D, Teuteberg JJ, Tedford RJ, Birati EY. Coronavirus disease 2019 in heart transplant recipients: Risk factors, immunosuppression, and outcomes. J Heart Lung Transplant 2021; 40:926-935. [PMID: 34140222 PMCID: PMC8131557 DOI: 10.1016/j.healun.2021.05.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/28/2021] [Accepted: 05/11/2021] [Indexed: 12/14/2022] Open
Abstract
Background COVID-19 continues to inflict significant morbidity and mortality, particularly on patients with preexisting health conditions. The clinical course, outcomes, and significance of immunosuppression regimen in heart transplant recipients with COVID-19 remains unclear. Methods We included the first 99 heart transplant recipients at participating centers with COVID-19 and followed patients until resolution. We collected baseline information, symptoms, laboratory studies, vital signs, and outcomes for included patients. The association of immunosuppression regimens at baseline with severe disease were compared using logistic regression, adjusting for age and time since transplant. Results The median age was 60 years, 25% were female, and 44% were white. The median time post-transplant to infection was 5.6 years. Overall, 15% died, 64% required hospital admission, and 7% remained asymptomatic. During the course of illness, only 57% of patients had a fever, and gastrointestinal symptoms were common. Tachypnea, oxygen requirement, elevated creatinine and inflammatory markers were predictive of severe course. Age ≥ 60 was associated with higher risk of death and the use of the combination of calcineurin inhibitor, antimetabolite, and prednisone was associated with more severe disease compared to the combination of calcineurin inhibitor and antimetabolite alone (adjusted OR = 7.3, 95% CI 1.8-36.2). Among hospitalized patients, 30% were treated for secondary infection, acute kidney injury was common and 17% required new renal replacement therapy. Conclusions We present the largest study to date of heart transplant patients with COVID-19 showing common atypical presentations and a high case fatality rate of 24% among hospitalized patients and 16% among symptomatic patients.
Collapse
Affiliation(s)
- Michael V Genuardi
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Noah Moss
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Supriya Shore
- Cardiovascular Division, University of Michigan, Ann Arbor, MI
| | - Esther Vorovich
- Division of Cardiology, Northwestern University, Chicago, IL
| | - Pavan Atluri
- Department of Cardiothoracic Surgery, University of Pennsylvania, Pennsylvania
| | - Maria Molina
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan Chambers
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tiffany Sharkoski
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eileen Hsich
- Heart and Vascular Institute at the Cleveland Clinic and Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine, Cleveland, OH
| | - Jerry D Estep
- Heart and Vascular Institute at the Cleveland Clinic and Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine, Cleveland, OH
| | - Anjali T Owens
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin M Alexander
- Division of Cardiovascular Medicine and the Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA
| | | | | | | | | | - MDc Joyce Wald
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kenneth B Margulies
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas C Hanff
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ross Zimmer
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Rhondalyn Mclean
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Himabindu Vidula
- Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Katherine Dodd
- Division of Cardiology, Northwestern University, Chicago, IL
| | - Emily A Blumberg
- Division of Infectious Diseases, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy A Mazurek
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lee R Goldberg
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jesus Alvarez-Garcia
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Donna Mancini
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeffrey J Teuteberg
- Division of Cardiovascular Medicine and the Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA
| | | | - Edo Y Birati
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania; Cardiovascular division, Poriya Medical Center, Bar Ilan University, Israel
| |
Collapse
|
24
|
Zamani P, Proto EA, Wilson N, Fazelinia H, Ding H, Spruce LA, Davila A, Hanff TC, Mazurek JA, Prenner SB, Desjardins B, Margulies KB, Kelly DP, Arany Z, Doulias PT, Elrod JW, Allen ME, McCormack SE, Schur GM, D'Aquilla K, Kumar D, Thakuri D, Prabhakaran K, Langham MC, Poole DC, Seeholzer SH, Reddy R, Ischiropoulos H, Chirinos JA. Multimodality assessment of heart failure with preserved ejection fraction skeletal muscle reveals differences in the machinery of energy fuel metabolism. ESC Heart Fail 2021; 8:2698-2712. [PMID: 33991175 PMCID: PMC8318475 DOI: 10.1002/ehf2.13329] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 02/25/2021] [Accepted: 03/12/2021] [Indexed: 02/06/2023] Open
Abstract
AIMS Skeletal muscle (SkM) abnormalities may impact exercise capacity in patients with heart failure with preserved ejection fraction (HFpEF). We sought to quantify differences in SkM oxidative phosphorylation capacity (OxPhos), fibre composition, and the SkM proteome between HFpEF, hypertensive (HTN), and healthy participants. METHODS AND RESULTS Fifty-nine subjects (20 healthy, 19 HTN, and 20 HFpEF) performed a maximal-effort cardiopulmonary exercise test to define peak oxygen consumption (VO2, peak ), ventilatory threshold (VT), and VO2 efficiency (ratio of total work performed to O2 consumed). SkM OxPhos was assessed using Creatine Chemical-Exchange Saturation Transfer (CrCEST, n = 51), which quantifies unphosphorylated Cr, before and after plantar flexion exercise. The half-time of Cr recovery (t1/2, Cr ) was taken as a metric of in vivo SkM OxPhos. In a subset of subjects (healthy = 13, HTN = 9, and HFpEF = 12), percutaneous biopsy of the vastus lateralis was performed for myofibre typing, mitochondrial morphology, and proteomic and phosphoproteomic analysis. HFpEF subjects demonstrated lower VO2,peak , VT, and VO2 efficiency than either control group (all P < 0.05). The t1/2, Cr was significantly longer in HFpEF (P = 0.005), indicative of impaired SkM OxPhos, and correlated with cycle ergometry exercise parameters. HFpEF SkM contained fewer Type I myofibres (P = 0.003). Proteomic analyses demonstrated (a) reduced levels of proteins related to OxPhos that correlated with exercise capacity and (b) reduced ERK signalling in HFpEF. CONCLUSIONS Heart failure with preserved ejection fraction patients demonstrate impaired functional capacity and SkM OxPhos. Reductions in the proportions of Type I myofibres, proteins required for OxPhos, and altered phosphorylation signalling in the SkM may contribute to exercise intolerance in HFpEF.
Collapse
Affiliation(s)
- Payman Zamani
- Penn Cardiovascular Institute, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Elizabeth A Proto
- Penn Cardiovascular Institute, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Neil Wilson
- Center for Magnetic Resonance and Optical Imaging, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hossein Fazelinia
- Proteomics Core, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Hua Ding
- Proteomics Core, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lynn A Spruce
- Proteomics Core, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Antonio Davila
- Penn Acute Care Research Collaboration, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas C Hanff
- Penn Cardiovascular Institute, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Jeremy A Mazurek
- Penn Cardiovascular Institute, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Stuart B Prenner
- Penn Cardiovascular Institute, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Benoit Desjardins
- Cardiovascular Imaging Section, Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Kenneth B Margulies
- Penn Cardiovascular Institute, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Daniel P Kelly
- Penn Cardiovascular Institute, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Zoltan Arany
- Penn Cardiovascular Institute, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | | | - John W Elrod
- Center for Translational Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Mitchell E Allen
- Department of Human Nutrition, Foods, and Exercise, Virginia Tech, Blacksburg, VA, USA
| | - Shana E McCormack
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Kevin D'Aquilla
- Center for Magnetic Resonance and Optical Imaging, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dushyant Kumar
- Center for Magnetic Resonance and Optical Imaging, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Deepa Thakuri
- Center for Magnetic Resonance and Optical Imaging, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Karthik Prabhakaran
- Center for Magnetic Resonance and Optical Imaging, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael C Langham
- Laboratory for Structural, Physiologic and Functional Imaging, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David C Poole
- Departments of Kinesiology, Anatomy, and Physiology, Kansas State University, Manhattan, KS, USA
| | - Steven H Seeholzer
- Proteomics Core, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ravinder Reddy
- Center for Magnetic Resonance and Optical Imaging, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Harry Ischiropoulos
- Children's Hospital of Philadelphia Research Institute, Philadelphia, PA, USA
| | - Julio A Chirinos
- Penn Cardiovascular Institute, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| |
Collapse
|
25
|
Birati EY, Najjar SS, Tedford RJ, Houston BA, Shore S, Vorovich E, Atluri P, Urgo K, Molina M, Chambers S, Escobar N, Hsich E, Estep JD, Alexander KM, Teuteberg JJ, Chaudhry SP, Ravichandran A, DeVore AD, Margulies KB, Hanff TC, Zimmer R, Kilic A, Wald JW, Vidula H, Martens J, Blumberg EA, Mazurek JA, Owens AT, Goldberg LR, Alvarez-Garcia J, Mancini DM, Moss N, Genuardi MV. Characteristics and Outcomes of COVID-19 in Patients on Left Ventricular Assist Device Support. Circ Heart Fail 2021; 14:e007957. [PMID: 33813838 PMCID: PMC8059761 DOI: 10.1161/circheartfailure.120.007957] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Supplemental Digital Content is available in the text. Background: The coronavirus disease 2019 (COVID-19) pandemic continues to afflict millions of people worldwide. Patients with end-stage heart failure and left ventricular assist devices (LVADs) may be at risk for severe COVID-19 given a high prevalence of complex comorbidities and functional impaired immunity. The objective of this study is to describe the clinical characteristics and outcomes of COVID-19 in patients with end-stage heart failure and durable LVADs. Methods: The Trans-CoV-VAD registry is a multi-center registry of LVAD and cardiac transplant patients in the United States with confirmed COVID-19. Patient characteristics, exposure history, presentation, laboratory data, course, and clinical outcomes were collected by participating institutions and reviewed by a central data repository. This report represents the participation of the first 9 centers to report LVAD data into the registry. Results: A total of 40 patients were included in this cohort. The median age was 56 years (interquartile range, 46–68), 14 (35%) were women, and 21 (52%) were Black. Among the most common presenting symptoms were cough (41%), fever, and fatigue (both 38%). A total of 18% were asymptomatic at diagnosis. Only 43% of the patients reported either subjective or measured fever during the entire course of illness. Over half (60%) required hospitalization, and 8 patients (20%) died, often after lengthy hospitalizations. Conclusions: We present the largest case series of LVAD patients with COVID-19 to date. Understanding these characteristics is essential in an effort to improve the outcome of this complex patient population.
Collapse
Affiliation(s)
- Edo Y Birati
- Cardiovascular Division, Department of Medicine (E.Y.B., K.U., M.M., S.C., N.E., K.B.M., T.C.H., R.Z., J.W.W., J.A.M., A.T.O., L.R.G., M.V.G.), University of Pennsylvania, Philadelphia.,Perelman School of Medicine and Cardiovascular Outcomes, Quality, and Evaluative Research Center (E.Y.B.), University of Pennsylvania, Philadelphia.,Cardiovascular Division, Poriya Medical Center, Bar-Ilan University, Israel. (E.Y.B.)
| | - Samer S Najjar
- MedStar Washington Hospital Center, Washington, DC (S.S.N.)
| | - Ryan J Tedford
- Medical University of South Carolina, Charleston, SC (R.J.T., B.A.H.)
| | - Brian A Houston
- Medical University of South Carolina, Charleston, SC (R.J.T., B.A.H.)
| | - Supriya Shore
- Cardiovascular Division, University of Michigan, Ann Arbor (S.S.)
| | - Esther Vorovich
- Division of Cardiology, Northwestern University, Chicago, IL (E.V.)
| | - Pavan Atluri
- Department of Cardiothoracic Surgery (P.A.), University of Pennsylvania, Philadelphia
| | - Kimberly Urgo
- Cardiovascular Division, Department of Medicine (E.Y.B., K.U., M.M., S.C., N.E., K.B.M., T.C.H., R.Z., J.W.W., J.A.M., A.T.O., L.R.G., M.V.G.), University of Pennsylvania, Philadelphia
| | - Maria Molina
- Cardiovascular Division, Department of Medicine (E.Y.B., K.U., M.M., S.C., N.E., K.B.M., T.C.H., R.Z., J.W.W., J.A.M., A.T.O., L.R.G., M.V.G.), University of Pennsylvania, Philadelphia
| | - Susan Chambers
- Cardiovascular Division, Department of Medicine (E.Y.B., K.U., M.M., S.C., N.E., K.B.M., T.C.H., R.Z., J.W.W., J.A.M., A.T.O., L.R.G., M.V.G.), University of Pennsylvania, Philadelphia
| | - Nicole Escobar
- Cardiovascular Division, Department of Medicine (E.Y.B., K.U., M.M., S.C., N.E., K.B.M., T.C.H., R.Z., J.W.W., J.A.M., A.T.O., L.R.G., M.V.G.), University of Pennsylvania, Philadelphia
| | - Eileen Hsich
- Heart and Vascular Institute at the Cleveland Clinic and Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine, OH (E.H., J.D.E.)
| | - Jerry D Estep
- Heart and Vascular Institute at the Cleveland Clinic and Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine, OH (E.H., J.D.E.)
| | - Kevin M Alexander
- Division of Cardiovascular Medicine and the Stanford Cardiovascular Institute, Stanford University School of Medicine, CA (K.M.A., J.J.T.)
| | - Jeffrey J Teuteberg
- Division of Cardiovascular Medicine and the Stanford Cardiovascular Institute, Stanford University School of Medicine, CA (K.M.A., J.J.T.)
| | - Sunit-Preet Chaudhry
- St Vincent Medical Group, St Vincent Heart Center, Indianapolis, IN (S.-P.C., A.R.)
| | - Ashwin Ravichandran
- St Vincent Medical Group, St Vincent Heart Center, Indianapolis, IN (S.-P.C., A.R.)
| | - Adam D DeVore
- Duke Clinical Research Institute and Department of Medicine, Duke University School of Medicine, Durham, NC (A.D.D.)
| | - Kenneth B Margulies
- Cardiovascular Division, Department of Medicine (E.Y.B., K.U., M.M., S.C., N.E., K.B.M., T.C.H., R.Z., J.W.W., J.A.M., A.T.O., L.R.G., M.V.G.), University of Pennsylvania, Philadelphia
| | - Thomas C Hanff
- Cardiovascular Division, Department of Medicine (E.Y.B., K.U., M.M., S.C., N.E., K.B.M., T.C.H., R.Z., J.W.W., J.A.M., A.T.O., L.R.G., M.V.G.), University of Pennsylvania, Philadelphia
| | - Ross Zimmer
- Cardiovascular Division, Department of Medicine (E.Y.B., K.U., M.M., S.C., N.E., K.B.M., T.C.H., R.Z., J.W.W., J.A.M., A.T.O., L.R.G., M.V.G.), University of Pennsylvania, Philadelphia
| | - Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, PA (A.K.)
| | - Joyce W Wald
- Cardiovascular Division, Department of Medicine (E.Y.B., K.U., M.M., S.C., N.E., K.B.M., T.C.H., R.Z., J.W.W., J.A.M., A.T.O., L.R.G., M.V.G.), University of Pennsylvania, Philadelphia
| | - Himabindu Vidula
- Division of Cardiology, University of Rochester School of Medicine and Dentistry, NY (H.V., J.M.)
| | - John Martens
- Division of Cardiology, University of Rochester School of Medicine and Dentistry, NY (H.V., J.M.)
| | - Emily A Blumberg
- Division of Infectious Diseases (E.A.B.), University of Pennsylvania, Philadelphia
| | - Jeremy A Mazurek
- Cardiovascular Division, Department of Medicine (E.Y.B., K.U., M.M., S.C., N.E., K.B.M., T.C.H., R.Z., J.W.W., J.A.M., A.T.O., L.R.G., M.V.G.), University of Pennsylvania, Philadelphia
| | - Anjali T Owens
- Cardiovascular Division, Department of Medicine (E.Y.B., K.U., M.M., S.C., N.E., K.B.M., T.C.H., R.Z., J.W.W., J.A.M., A.T.O., L.R.G., M.V.G.), University of Pennsylvania, Philadelphia
| | - Lee R Goldberg
- Cardiovascular Division, Department of Medicine (E.Y.B., K.U., M.M., S.C., N.E., K.B.M., T.C.H., R.Z., J.W.W., J.A.M., A.T.O., L.R.G., M.V.G.), University of Pennsylvania, Philadelphia
| | - Jesus Alvarez-Garcia
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY (J.A.-G., D.M.M., N.M.)
| | - Donna M Mancini
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY (J.A.-G., D.M.M., N.M.)
| | - Noah Moss
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY (J.A.-G., D.M.M., N.M.)
| | - Michael V Genuardi
- Cardiovascular Division, Department of Medicine (E.Y.B., K.U., M.M., S.C., N.E., K.B.M., T.C.H., R.Z., J.W.W., J.A.M., A.T.O., L.R.G., M.V.G.), University of Pennsylvania, Philadelphia
| |
Collapse
|
26
|
Diamant MJ, Fox AL, Modi VA, Joshi AA, Clark DE, Bichell DP, Cedars A, Fowler R, Frischhertz BP, Mazurek JA, Schlendorf KH, Shah AS, Zalawadiya SK, Lindenfeld J, Menachem JN. No survival benefit associated with waiting for non-lung donor heart transplants for adult recipients with congenital heart disease. Clin Transplant 2021; 35:e14266. [PMID: 33615562 DOI: 10.1111/ctr.14266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/30/2021] [Accepted: 02/13/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Adults with congenital heart disease (CHD) awaiting heart transplant (HT) have higher mortality and waitlist removal due to clinical deterioration than those without CHD. The selective use of non-lung donors (NLD) to recover donor pulmonary vasculature to assist in graft implantation may be a contributing factor and is supported by consensus statements despite the recent use of pericardium or graft material as an alternative in pulmonary vascular reconstruction. The impact of selecting NLD for CHD recipients on wait time and mortality has not been evaluated. METHODS/RESULTS In the United Network for Organ Sharing (UNOS) Registry, 1271 HT recipients age ≥ 18 with CHD were identified between 1987 and 2016, 68% of which had NLDs. Prior to HT, NLD recipients were significantly less likely to be listed UNOS Status 1A, require mechanical ventilation, or intra-aortic balloon pump support. There was no difference in mean waitlist time (254 vs. 278 days, p = .31), 1-year mortality (82% vs. 80%, p = .81; adjusted odds ratio 1.32, 95% confidence interval [CI] 0.96-1.83, p = .08), or overall mortality (adjusted hazard ratio 1.08, 95% CI 0.86-1.36, p = .48) between recipients from NLD and concomitant lung donors. CONCLUSIONS Adult CHD patients who are less critically ill or listed at a lower status are more likely to receive HT from NLD. There is no overall mortality benefit associated with this practice. While specific cases may necessitate waiting for NLD, programs need to re-evaluate whether this should remain a more widespread practice among CHD patients.
Collapse
Affiliation(s)
- Michael J Diamant
- Division of Cardiology, Royal Columbian Hospital, New Westminster, BC, Canada.,Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Arieh L Fox
- Mount Sinai Heart, Mount Sinai Medical Center, St Luke's Hospital, New York, NY, USA
| | - Vivek A Modi
- St. Luke's University Health Network, Bethlehem, PA, USA
| | - Aditya A Joshi
- Mount Sinai Heart, Mount Sinai St Luke's Hospital, New York, NY, USA
| | - Daniel E Clark
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David P Bichell
- Division of Pediatric Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ari Cedars
- Division of Cardiology, The Johns Hopkins Hospital and Johns Hopkins Children Center, Baltimore, MD, USA
| | - Rachel Fowler
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Jeremy A Mazurek
- Advanced Heart Failure/Transplantation Program, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Kelly H Schlendorf
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ashish S Shah
- Division of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sandip K Zalawadiya
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - JoAnn Lindenfeld
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan N Menachem
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
27
|
Edelson JB, Edwards JJ, Katcoff H, Mondal A, Reza N, Hanff TC, Griffis H, Mazurek JA, Wald J, Owens AT, Burstein DS, Atluri P, O'Connor MJ, Goldberg LR, Zamani P, Groeneveld PW, Rossano JW, Lin KY, Birati EY. An Increasing Burden of Disease: Emergency Department Visits Among Patients With Ventricular Assist Devices From 2010 to 2017. J Am Heart Assoc 2021; 10:e018035. [PMID: 33543642 PMCID: PMC7955344 DOI: 10.1161/jaha.120.018035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background With a growing population of patients supported by ventricular assist devices (VADs) and the improvement in survival of this patient population, understanding the healthcare system burden is critical to improving outcomes. Thus, we sought to examine national estimates of VAD-related emergency department (ED) visits and characterize their demographic, clinical, and outcomes profile. Additionally, we tested the hypotheses that resource use increased and mortality improved over time. Methods and Results This retrospective database analysis uses encounter-level data from the 2010 to 2017 Nationwide Emergency Department Sample. The primary outcome was mortality. From 2010 to 2017, >880 million ED visits were evaluated, with 44 042 VAD-related ED visits identified. The annual mean visits were 5505 (SD 4258), but increased 16-fold from 2010 to 2017 (824 versus 13 155). VAD-related ED visits frequently resulted in admission (72%) and/or death (3.0%). Median inflation-adjusted charges were $25 679 (interquartile range, $7450, $63 119) per encounter. The most common primary diagnoses were cardiac (22%), and almost 30% of encounters were because of bleeding, stroke, or device complications. From 2010 to 2017, admission and mortality decreased from 82% to 71% and 3.4% to 2.4%, respectively (P for trends <0.001, both). Conclusions We present the first study using national-level data to characterize the growing ED resource use and financial burden of patients supported by VAD. During the past decade, admission and mortality rates decreased but remain substantial; in 2017 ≈1 in every 40 VAD ED encounters resulted in death, making it critical that clinical decision-making be optimized for patients with VAD to maximize good outcomes.
Collapse
Affiliation(s)
- Jonathan B Edelson
- Division of Cardiology Cardiac Center the Children's Hospital of PhiladelphiaUniversity of Pennsylvania Perelman School of Medicine Philadelphia PA.,Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA.,Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia PA
| | - Jonathan J Edwards
- Division of Cardiology Cardiac Center the Children's Hospital of PhiladelphiaUniversity of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Hannah Katcoff
- Department of Biomedical Health Informatics, Healthcare Analytics Unit the Children's Hospital of Philadelphia Philadelphia PA
| | - Antara Mondal
- Department of Biomedical Health Informatics, Healthcare Analytics Unit the Children's Hospital of Philadelphia Philadelphia PA
| | - Nosheen Reza
- Cardiovascular Division Department of Medicine Perelman School of Medicine Philadelphia PA
| | - Thomas C Hanff
- Cardiovascular Division Department of Medicine Perelman School of Medicine Philadelphia PA
| | - Heather Griffis
- Department of Biomedical Health Informatics, Healthcare Analytics Unit the Children's Hospital of Philadelphia Philadelphia PA
| | - Jeremy A Mazurek
- Cardiovascular Division Department of Medicine Perelman School of Medicine Philadelphia PA
| | - Joyce Wald
- Cardiovascular Division Department of Medicine Perelman School of Medicine Philadelphia PA
| | - Anjali T Owens
- Cardiovascular Division Department of Medicine Perelman School of Medicine Philadelphia PA
| | - Danielle S Burstein
- Division of Cardiology Cardiac Center the Children's Hospital of PhiladelphiaUniversity of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Pavan Atluri
- Department of Biomedical Health Informatics, Healthcare Analytics Unit the Children's Hospital of Philadelphia Philadelphia PA
| | - Matthew J O'Connor
- Division of Cardiology Cardiac Center the Children's Hospital of PhiladelphiaUniversity of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Lee R Goldberg
- Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA.,Cardiovascular Division Department of Medicine Perelman School of Medicine Philadelphia PA
| | - Payman Zamani
- Cardiothoracic Surgery Perelman School of Medicine Philadelphia PA
| | - Peter W Groeneveld
- Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA.,Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia PA.,General Internal Medicine Division Department of Medicine Perelman School of Medicine Philadelphia PA
| | - Joseph W Rossano
- Division of Cardiology Cardiac Center the Children's Hospital of PhiladelphiaUniversity of Pennsylvania Perelman School of Medicine Philadelphia PA.,Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA
| | - Kimberly Y Lin
- Division of Cardiology Cardiac Center the Children's Hospital of PhiladelphiaUniversity of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Edo Y Birati
- Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania Philadelphia PA.,Cardiovascular Division Department of Medicine Perelman School of Medicine Philadelphia PA.,Cardiovascular Division Poriya Medical CenterBar Ilan University Ramat Gan Israel
| |
Collapse
|
28
|
Grandin EW, Troutman GS, Gulati AA, Zamani P, Mazurek JA, Atluri P, Rame JE. A Modified Grading System for Early Right Heart Failure Matches Functional Outcomes and Survival After Left Ventricular Assist Devices. ASAIO J 2021; 67:185-191. [PMID: 32618585 DOI: 10.1097/mat.0000000000001203] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Early right heart failure (ERHF) remains a common complication after continuous-flow left ventricular assist device (cf-LVAD) and has been associated with increased mortality. The specific criteria used to define ERHF remain somewhat arbitrary. Correlating the degree of ERHF with outcomes after LVAD could inform a more clinically relevant definition. We identified 196 patients who underwent first durable cf-LVAD between 2008 and 2015 at a single center. Postimplant ERHF was graded as absent, mild (requiring inotropic support for 14-20 days), moderate (inotropes for ≥ 21 days), or severe (requiring unplanned RVAD at any time during the index hospitalization). ERHF was associated with clinical outcomes including 1 year survival and New York Heart Association (NYHA) class and 6 minute walk distance (6MWD) at 3 and 6 months. Survival was assessed using the Kaplan-Meier method with log-rank testing and multivariate Cox proportional-hazards modeling. Compared to patients without ERHF, those with mild ERHF had similar 1 year survival (hazard ratio [HR] 0.69, 95% confidence interval [CI]: 0.26-1.80, p = 0.45), while mortality was substantially increased in patients with moderate (HR 2.65, 95% CI: 1.27-5.54, p = 0.009) and severe ERHF (HR 8.16, 95% CI: 3.97-16.76, p < 0.0001). The severity of ERHF was associated with 6MWD at both 3 months (p = 0.001) and 6 months (p = 0.013). The relationship between ERHF and postimplant survival and functional status persisted in multivariate modeling. A simple, modified grading system for ERHF severity is strongly associated with 1 year survival and functional capacity after cf-LVAD. These results argue against using a binary definition for ERHF and suggest the need to modify definition of ERHF severity.
Collapse
Affiliation(s)
- E Wilson Grandin
- From the Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School. Boston, Massachusetts
| | - Gregory S Troutman
- Sidney Kimmel Medical College, Thomas Jefferson University. Philadelphia, Pennsylvania
| | - Arune A Gulati
- Department of Medicine, Johns Hopkins University School of Medicine. Baltimore, Maryland
| | - Payman Zamani
- Division of Cardiovascular Medicine, University of Pennsylvania, Perelman School of Medicine. Philadelphia, Pennsylvania
| | - Jeremy A Mazurek
- Division of Cardiovascular Medicine, University of Pennsylvania, Perelman School of Medicine. Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiothoracic Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - J Eduardo Rame
- Division of Cardiovascular Medicine, University of Pennsylvania, Perelman School of Medicine. Philadelphia, Pennsylvania
| |
Collapse
|
29
|
Burstein DS, Rossano JW, Griffis H, Zhang X, Fowler R, Frischertz B, Kim YY, Lindenfield J, Mazurek JA, Edelson JB, Menachem JN. Greater admissions, mortality and cost of heart failure in adults with congenital heart disease. Heart 2020; 107:807-813. [PMID: 33361349 DOI: 10.1136/heartjnl-2020-318246] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Limited contemporary data exist regarding outcomes and resource use among adults with congenital heart disease and heart failure (ACHD-HF). This study compared outcomes, emergency department (ED) and hospital resource use, and advanced heart failure (HF) therapies in ACHD-HF versus non-ACHD with HF (HF-non-ACHD). METHODS The Nationwide Emergency Department Sample and Nationwide Inpatient Sample were used to analyse outcomes and resource use among ACHD-HF ED visits and hospitalisations from 2006 to 2016. ACHD-HF was stratified by single-ventricle (SV) and two-ventricle (2V) disease. RESULTS A total of 76 557 ACHD-HF visits (3.6% SV physiology) and 31 137 414 HF-non-ACHD visits were analysed. ACHD-HFs were younger (SV 33 years (IQR 25-44), 2V 62 years (IQR 45-76); HF-non-ACHD 74 years (IQR 63-83); p<0.001). ACHD-HFs had higher ED admissions (78% vs 70%, p<0.001), longer hospital length of stay (5 days (IQR 2-8) vs 4 days (IQR 2-7), p<0.001) and greater hospital costs ($49K (IQR 2K-121K) vs $32K (17K-66K), p<0.001). Mortality was significantly higher among ACHD-HFs with SV physiology (6.6%; OR 1.6, 95% CI 1.1 to 2.3) or 2V physiology (6.3%; OR 1.4, 95% CI 1.3 to 1.5) versus HF-non-ACHD (5.5%). ACHF-HF hospitalisations increased more (46% vs 6% HF-non-ACHD) over a 10-year period, but the proportion receiving ventricular assist device (VAD) (ACHD-HF -2% vs HF-non-ACHD 294%) or transplant (ACHD-HF -37% vs HF-non-ACHD 73%) decreased. CONCLUSION ACHD-HFs have significant ED and hospital resource use that has increased over the past 10 years. However, advanced HF therapies (VAD and transplantation) are less commonly used compared with those without adult congenital heart disease.
Collapse
Affiliation(s)
- Danielle S Burstein
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joseph W Rossano
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Heather Griffis
- Healthcare Analytics Unit, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Xuemei Zhang
- Healthcare Analytics Unit, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rachel Fowler
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Benjamin Frischertz
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Yuli Y Kim
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - JoAnn Lindenfield
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jeremy A Mazurek
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jonathan B Edelson
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jonathan N Menachem
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
30
|
Bhattacharya PT, Hameed AMA, Bhattacharya ST, Chirinos JA, Hwang WT, Birati EY, Menachem JN, Chatterjee S, Giri JS, Kawut SM, Kimmel SE, Mazurek JA. Risk factors for 30-day readmission in adults hospitalized for pulmonary hypertension. Pulm Circ 2020; 10:2045894020966889. [PMID: 33282194 PMCID: PMC7686634 DOI: 10.1177/2045894020966889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/24/2020] [Indexed: 01/15/2023] Open
Abstract
Readmissions for pulmonary hypertension are poorly understood and understudied.
We sought to determine national estimates and risk factors for 30-day
readmission after pulmonary hypertension-related hospitalizations. We utilized
the Healthcare Cost and Utilization Project Nationwide Readmission Database,
which has weighted estimates of roughly 35 million discharges in the US. Adult
patients with primary International Classification of Disease, Ninth Revision,
Clinical Modification diagnosis codes of 416.0 and 416.8 for primary and
secondary pulmonary hypertension with an index admission between 2012 and 2014
and any readmission within 30 days of the index event were identified.
Predictors of 30-day readmission were identified using multivariable logistic
regression with adjustment for covariates. Results showed that the national
estimate for Primary Pulmonary Hypertension vs Secondary Pulmonary
Hypertension-related index events between 2012 and 2014 with 30-day readmission
was 247 vs 2550 corresponding to a national readmission risk estimate of 17% vs
18.3%, respectively. The presence of fluid and electrolyte disorders, renal
failure, and alcohol abuse were associated with increased risk of readmission in
Primary Pulmonary Hypertension, while factors associated with Secondary
Pulmonary Hypertension readmissions included anemia, congestive heart failure,
lung disease, fluid and electrolyte disorders, renal failure, diabetes, and
liver disease. The median cost of Primary Pulmonary Hypertension admissions and
readmissions were $46,132 (IQR: $25,384–$85,647) and $41,604.50 (IQR:
$22,481.50–$84,420.50), respectively. The median costs of Secondary Pulmonary
Hypertension admissions and readmissions were $34,893 (IQR: $19,670–$66,143) and
$36,279 (IQR: $19,059–$74,679), respectively. In conclusion, approximately 19%
of Primary Pulmonary Hypertension and Secondary Pulmonary Hypertension
hospitalizations result in 30-day readmission, with significant costs accrued
during the index hospitalization and readmission. With evolving clinical
terminology and diagnostic codes, future study will need to better clarify
underlying factors associated with readmissions amongst pulmonary hypertension
sub-types, and identify methods and procedures to minimize readmission risk.
Collapse
Affiliation(s)
- Priyanka T Bhattacharya
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Asif M Abdul Hameed
- Department of Pulmonary Disease and Critical Care Medicine, Wayne State University, Detroit, MI, USA
| | | | - Julio A Chirinos
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Wei-Ting Hwang
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Edo Y Birati
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan N Menachem
- Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Saurav Chatterjee
- Department of Cardiovascular Medicine, St Francis Hospital of the University of Connecticut, Hartford, CT, USA
| | - Jay S Giri
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Steven M Kawut
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Stephen E Kimmel
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jeremy A Mazurek
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
31
|
Rao SD, Adusumalli S, Mazurek JA. Corrigendum to: Pulmonary Hypertension in Heart Failure Patients. Card Fail Rev 2020; 6:e30. [PMID: 33149941 PMCID: PMC7607380 DOI: 10.15420/cfr.2020.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Sriram D Rao
- Advanced Heart Failure/Transplantation Programme, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania Philadelphia, PA, US
| | - Srinath Adusumalli
- Department of Medicine, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania Philadelphia, PA, US
| | - Jeremy A Mazurek
- Advanced Heart Failure/Transplantation Programme, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania Philadelphia, PA, US.,Pulmonary Hypertension Programme, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania Philadelphia, PA, US
| |
Collapse
|
32
|
Sun W, Tang Y, Tai YY, Handen A, Zhao J, Speyer G, Al Aaraj Y, Watson A, Romanelli ME, Sembrat J, Rojas M, Simon MA, Zhang Y, Lee J, Xiong Z, Dutta P, Vasamsetti SB, McNamara D, McVerry B, McTiernan CF, Sciurba FC, Kim S, Smith KA, Mazurek JA, Han Y, Vaidya A, Nouraie SM, Kelly NJ, Chan SY. SCUBE1 Controls BMPR2-Relevant Pulmonary Endothelial Function: Implications for Diagnostic Marker Development in Pulmonary Arterial Hypertension. JACC Basic Transl Sci 2020; 5:1073-1092. [PMID: 33294740 PMCID: PMC7691287 DOI: 10.1016/j.jacbts.2020.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 08/26/2020] [Accepted: 08/26/2020] [Indexed: 12/27/2022]
Abstract
Utilizing publicly available ribonucleic acid sequencing data, we identified SCUBE1 as a BMPR2-related gene differentially expressed between induced pluripotent stem cell-endothelial cells derived from pulmonary arterial hypertension (PAH) patients carrying pathogenic BMPR2 mutations and control patients without mutations. Endothelial SCUBE1 expression was decreased by known triggers of PAH, and its down-regulation recapitulated known BMPR2-associated endothelial pathophenotypes in vitro. Meanwhile, SCUBE1 concentrations were reduced in plasma obtained from PAH rodent models and patients with PAH, whereas plasma concentrations were tightly correlated with hemodynamic markers of disease severity. Taken together, these data implicate SCUBE1 as a novel contributor to PAH pathogenesis with potential therapeutic, diagnostic, and prognostic applications.
Collapse
Key Words
- BMP, bone morphogenetic protein
- BMPR2
- EC, endothelial cell
- PAEC, pulmonary arterial endothelial cell
- PAH, pulmonary arterial hypertension
- PAP, pulmonary artery pressure
- PCWP, pulmonary capillary wedge pressure
- PH, pulmonary hypertension
- PVR, pulmonary vascular resistance
- RV, right ventricle
- SCUBE1
- WSPH, World Symposium on Pulmonary Hypertension
- endothelium
- iPSC-EC, induced pluripotent stem cell-endothelial cell
- mPAP, mean pulmonary artery pressure
- pulmonary hypertension
Collapse
Affiliation(s)
- Wei Sun
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ying Tang
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yi-Yin Tai
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Adam Handen
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jingsi Zhao
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Gil Speyer
- Research Computing, Arizona State University, Tempe, Arizona, USA
| | - Yassmin Al Aaraj
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Annie Watson
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Makenna E Romanelli
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John Sembrat
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mauricio Rojas
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Marc A Simon
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yingze Zhang
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Janet Lee
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Zeyu Xiong
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Partha Dutta
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sathish Badu Vasamsetti
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Dennis McNamara
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Bryan McVerry
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Charles F McTiernan
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Frank C Sciurba
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Seungchan Kim
- Center for Computational Systems Biology, Department of Electrical and Computer Engineering, Roy G. Perry College of Engineering, Prairie View A and M University, Prairie View, Texas, USA
| | - Kerri Akaya Smith
- Division of Pulmonary Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeremy A Mazurek
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yuchi Han
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anjali Vaidya
- Cardiovascular Division, Temple University Health Systems, Philadelphia, Pennsylvania, USA
| | - Seyed Mehdi Nouraie
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Neil J Kelly
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Stephen Y Chan
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology and Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
33
|
Han Y, Forfia P, Vaidya A, Mazurek JA, Park MH, Ramani G, Chan SY, Waxman AB. Ranolazine Improves Right Ventricular Function in Patients With Precapillary Pulmonary Hypertension: Results From a Double-Blind, Randomized, Placebo-Controlled Trial. J Card Fail 2020; 27:253-257. [PMID: 33223140 DOI: 10.1016/j.cardfail.2020.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 10/17/2020] [Accepted: 10/21/2020] [Indexed: 11/17/2022]
Abstract
INTRODUCTION A major outcome determinant in patients with precapillary pulmonary hypertension (PH) is right ventricular (RV) function. We studied the effect of ranolazine on RV function over 6 months using cardiovascular magnetic resonance (CMR) imaging in patients with precapillary PH (groups I, III, and IV). METHODS AND RESULTS We enrolled patients with PH and RV dysfunction (CMR imaging ejection fraction [EF] of <45%) in a longitudinal, randomized, double-blinded, placebo controlled, multicenter study of ranolazine treatment. All enrolled patients were on stable PH-specific therapy. Enrolled patients were assessed using CMR imaging, New York Heart Association functional class, N-terminal pro brain natriuretic peptide, 6-minute walk test, and quality of life health outcomes at baseline and repeated at the end of treatment. The primary outcome was change in RVEF after 6 months of treatment. Analysis of covariance was used to analyze the longitudinal changes taking into account baseline values, age, and sex, based on per protocol population. Twenty-two patients were enrolled, and 9 patients completed follow-up CMR imaging after ranolazine treatment and 6 completed placebo treatment. There was significant increase in RVEF at end of treatment compared with baseline in the ranolazine group adjusted for baseline values, age, and sex. There were no statistically significant changes in secondary outcomes such as changes in New York Heart Association functional class, 6-minute walk distance, N-terminal pro brain natriuretic peptide, or quality of life measures. Ranolazine treated patients experienced a higher number of adverse events, but only one was discontinued owing to side effects. CONCLUSIONS Ranolazine may improve RV function in patients with precapillary PH. Larger studies are needed to confirm the beneficial effects of ranolazine.
Collapse
Affiliation(s)
- Yuchi Han
- Cardiovascular Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Paul Forfia
- Cardiovascular Division, Temple University, Philadelphia, Pennsylvania, USA
| | - Anjali Vaidya
- Cardiovascular Division, Temple University, Philadelphia, Pennsylvania, USA
| | - Jeremy A Mazurek
- Cardiovascular Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Myung H Park
- Franciscan Heart Failure Clinic at St. Joseph, Tacoma, Washington, USA
| | - Gautam Ramani
- Cardiovascular Division, University of Maryland, Baltimore, Maryland, USA
| | - Stephen Y Chan
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Aaron B Waxman
- Center for Pulmonary Heart Disease, Heart and Vascular and Lung Centers, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
34
|
Shore S, Hanff TC, Mazurek JA, Seigerman M, Zhang R, Grandin EW, Vorovich E, Mather P, Olt C, Howard J, Wald J, Acker MA, Goldberg LR, Atluri P, Margulies KB, Rame JE, Birati EY. The effect of transfusion of blood products on ventricular assist device support outcomes. ESC Heart Fail 2020; 7:3573-3581. [PMID: 33263224 PMCID: PMC7754735 DOI: 10.1002/ehf2.12780] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 04/17/2020] [Accepted: 05/07/2020] [Indexed: 11/05/2022] Open
Abstract
AIMS Perioperative blood transfusions are common among patients undergoing left ventricular assist device (LVAD) implantation. The association between blood product transfusion at the time of LVAD implantation and mortality has not been described. METHODS AND RESULTS This was a retrospective cohort study of all patients who underwent continuous flow LVAD implantation at a single, large, tertiary care, academic centre, from 2008 to 2014. We assessed used of packed red blood cells (pRBCs), platelets, and fresh frozen plasma (FFP). Outcomes of interest included all-cause mortality and acute right ventricular (RV) failure. Standard regression techniques were used to examine the association between blood product exposure and outcomes of interest. A total of 170 patients were included in this study (mean age: 56.5 ± 15.5 years, 79.4% men). Over a median follow-up period of 11.2 months, for every unit of pRBC transfused, the hazard for mortality increased by 4% [hazard ratio (HR) 1.04; 95% CI 1.02-1.07] and odds for acute RV failure increased by 10% (odds ratio 1.10; 95% CI 1.05-1.16). This association persisted for other blood products including platelets (HR for mortality per unit 1.20; 95% CI 1.08-1.32) and FFP (HR for mortality per unit 1.08; 95% CI 1.04-1.12). The most significant predictor of perioperative blood product exposure was a lower pre-implant haemoglobin. CONCLUSIONS Perioperative blood transfusions among patients undergoing LVAD implantation were associated with a higher risk for all-cause mortality and acute RV failure. Of all blood products, FFP use was associated with worst outcomes. Future studies are needed to evaluate whether pre-implant interventions, such as intravenous iron supplementation, will improve the outcomes of LVAD candidates by decreasing need for transfusions.
Collapse
Affiliation(s)
- Supriya Shore
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Thomas C Hanff
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeremy A Mazurek
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew Seigerman
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Zhang
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edward W Grandin
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Esther Vorovich
- Division of Cardiovascular Medicine, Northwestern University, Chicago, IL, USA
| | - Paul Mather
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Caroline Olt
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jessica Howard
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Joyce Wald
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael A Acker
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Lee R Goldberg
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Pavan Atluri
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Kenneth B Margulies
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - J Eduardo Rame
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edo Y Birati
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
35
|
Ghio S, Mercurio V, Fortuni F, Forfia PR, Gall H, Ghofrani A, Mathai SC, Mazurek JA, Mukherjee M, Richter M, Scelsi L, Hassoun PM, Tello K. A comprehensive echocardiographic method for risk stratification in pulmonary arterial hypertension. Eur Respir J 2020; 56:13993003.00513-2020. [PMID: 32430422 DOI: 10.1183/13993003.00513-2020] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/07/2020] [Indexed: 02/01/2023]
Abstract
QUESTION ADDRESSED Echocardiography is not currently considered as providing sufficient prognostic information to serve as an integral part of treatment goals in pulmonary arterial hypertension (PAH). We tested the hypothesis that incorporation of multiple parameters reflecting right heart function would improve the prognostic value of this imaging modality. METHODS AND MAIN RESULTS We pooled individual patient data from a total of 517 patients (mean age 52±15 years, 64.8% females) included in seven observational studies conducted at five European and United States academic centres. Patients were subdivided into three groups representing progressive degrees of right ventricular dysfunction based on a combination of echocardiographic measurements, as follows. Group 1 (low risk): normal tricuspid annular plane systolic excursion (TAPSE) and nonsignificant tricuspid regurgitation (TR) (n=129); group 2 (intermediate risk): normal TAPSE and significant TR or impaired TAPSE and nondilated inferior vena cava (IVC) (n=256); group 3 (high risk): impaired TAPSE and dilated IVC (n=132). The 5-year cumulative survival rate was 82% in group 1, 63% in group 2 and 43% in group 3. Low-risk patients had better survival rates than intermediate-risk patients (log-rank Chi-squared 12.25; p<0.001) and intermediate-risk patients had better survival rates than high-risk patients (log-rank Chi-squared 26.25; p<0.001). Inclusion of other parameters such as right atrial area and pericardial effusion did not provide added prognostic value. ANSWER TO THE QUESTION The proposed echocardiographic approach integrating the evaluation of TAPSE, TR grade and IVC is effective in stratifying the risk for all-cause mortality in PAH patients, outperforming the prognostic parameters suggested by current guidelines.
Collapse
Affiliation(s)
- Stefano Ghio
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy .,These authors contributed equally as co-first authors
| | - Valentina Mercurio
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Dept of Translational Medical Sciences, Federico II University, Naples, Italy.,These authors contributed equally as co-first authors
| | - Federico Fortuni
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Dept of Molecular Medicine, Unit of Cardiology, University of Pavia, Pavia, Italy.,These authors contributed equally as co-first authors
| | - Paul R Forfia
- Pulmonary Hypertension, Right Heart Failure and Pulmonary Thromboendarterectomy Program, Temple University Hospital, Philadelphia, PA, USA
| | - Henning Gall
- University Hospital Giessen und Marburg GmbH, Pulmonary Hypertension Division, Medical Clinic II, Giessen, Germany
| | - Ardeschir Ghofrani
- University Hospital Giessen und Marburg GmbH, Pulmonary Hypertension Division, Medical Clinic II, Giessen, Germany
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeremy A Mazurek
- Dept of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Monica Mukherjee
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Manuel Richter
- University Hospital Giessen und Marburg GmbH, Pulmonary Hypertension Division, Medical Clinic II, Giessen, Germany
| | - Laura Scelsi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,These authors contributed equally as co-last authors
| | - Khodr Tello
- University Hospital Giessen und Marburg GmbH, Pulmonary Hypertension Division, Medical Clinic II, Giessen, Germany.,These authors contributed equally as co-last authors
| | | |
Collapse
|
36
|
Rao SD, Johnson B, Olia SE, Wald J, Medina V, Rame JE, Mazurek JA, Goldberg LR, Atluri P, Bermudez C, Acker M, Birati EY. Treatment With Impella Increases the Risk of De Novo Aortic Insufficiency Post Left Ventricular Assist Device Implant. J Card Fail 2020; 26:870-875. [PMID: 32681883 DOI: 10.1016/j.cardfail.2020.06.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 06/22/2020] [Accepted: 06/26/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Impella (Abiomed Inc, Danvers, MA) is a temporary mechanical support device positioned across the aortic valve, and can be used to support patient before LVAD implantation. There are no data on the incidence of aortic insufficiency (AI) in patients supported with Impella as a bridge to durable LVAD implantation. We sought to assess the incidence of AI in patients with Impella support as a bridge to durable left ventricular assist device (LVAD) implantation. METHODS We reviewed all patients undergoing primary LVAD implantation at the University of Pennsylvania from January 2015 onward, comparing those supported with Impella as temporary mechanical support with those supported by either venoarterial extracorporeal life support or an intra-aortic balloon pump. We reviewed transthoracic echocardiography preoperatively, as well as at 1 week, 1, 3, 6, 9, and 12 months after LVAD implantation. RESULTS A total of 215 echocardiograms were analyzed in 41 patients. Eleven patients were supported with Impella before LVAD implant-6 patients with Impella alone (5 with Impella CP, 1 with Impella 5.0) and 5 with Impella in conjunction with venoarterial extracorporeal life support (2 with Impella 2.5, 2 with Impella CP, and 1 with Impella 5.0). After LVAD implant, mild or moderate AI developed in 82% of patients supported with Impella (9 of 11) compared with 43% of those without Impella (13 of 30) (P = .038). CONCLUSIONS Patients supported by Impella as a bridge to durable LVAD have a higher risk of developing AI. Further studies are needed to assess this risk as the use of the Impella increases.
Collapse
Affiliation(s)
- Sriram D Rao
- Advanced Heart Failure/Transplantation Program, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bryce Johnson
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Salim E Olia
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce Wald
- Advanced Heart Failure/Transplantation Program, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Venessa Medina
- Advanced Heart Failure/Transplantation Program, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Eduardo Rame
- Advanced Heart Failure/Transplantation Program, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy A Mazurek
- Advanced Heart Failure/Transplantation Program, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lee R Goldberg
- Advanced Heart Failure/Transplantation Program, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Bermudez
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Acker
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edo Y Birati
- Advanced Heart Failure/Transplantation Program, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| |
Collapse
|
37
|
Hanff TC, Harhay MO, Kimmel SE, Molina M, Mazurek JA, Goldberg LR, Birati EY. Trends in Mechanical Support Use as a Bridge to Adult Heart Transplant Under New Allocation Rules. JAMA Cardiol 2020; 5:728-729. [PMID: 32293645 PMCID: PMC7160744 DOI: 10.1001/jamacardio.2020.0667] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 12/30/2019] [Indexed: 11/14/2022]
Affiliation(s)
- Thomas C. Hanff
- Perelman School of Medicine, Division of Cardiology, University of Pennsylvania, Philadelphia
| | - Michael O. Harhay
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Stephen E. Kimmel
- Perelman School of Medicine, Division of Cardiology, University of Pennsylvania, Philadelphia
| | - Maria Molina
- Perelman School of Medicine, Division of Cardiology, University of Pennsylvania, Philadelphia
| | - Jeremy A. Mazurek
- Perelman School of Medicine, Division of Cardiology, University of Pennsylvania, Philadelphia
| | - Lee R. Goldberg
- Perelman School of Medicine, Division of Cardiology, University of Pennsylvania, Philadelphia
| | - Edo Y. Birati
- Perelman School of Medicine, Division of Cardiology, University of Pennsylvania, Philadelphia
| |
Collapse
|
38
|
Geller BJ, Adusumalli S, Pugliese SC, Khatana SAM, Nathan A, Weinberg I, Jaff MR, Kobayashi T, Mazurek JA, Khandhar S, Yang L, Groeneveld PW, Giri JS. Outcomes of catheter-directed versus systemic thrombolysis for the treatment of pulmonary embolism: A real-world analysis of national administrative claims. Vasc Med 2020; 25:334-340. [PMID: 32338580 DOI: 10.1177/1358863x20903371] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Catheter-directed thrombolysis (CDT) and systemic thrombolysis (ST) are used to treat intermediate/high-risk pulmonary embolism (PE) in the absence of comparative safety and effectiveness data. We utilized a large administrative database to perform a comparative safety and effectiveness analysis of catheter-directed versus systemic thrombolysis. From the Optum® Clinformatics® Data Mart private-payer insurance claims database, we identified 100,744 patients hospitalized with PE between 2004 and 2014. We extracted demographic characteristics, high-risk PE features, components of the Elixhauser Comorbidity Index, and outcomes including intracranial hemorrhage (ICH), all-cause bleeding, and mortality among all patients receiving CDT and ST. We used propensity score methods to compare outcomes between matched cohorts adjusted for observed confounders. A total of 1915 patients (1.9%) received either CDT (n = 632) or ST (n = 1283). Patients in the CDT group had fewer high-risk features including less shock (5.4 vs 11.1%; p < 0.001) and cardiac arrest (6.8 vs 11.0%; p = 0.004). In 1:1 propensity-matched groups, ICH rates were 1.9% in both the CDT and ST groups (p = 1.0). All-cause bleeding was higher in the CDT group (15.9 vs 8.7%; p < 0.001), while in-hospital mortality was lower (6.5 vs 10.0%; p = 0.02). Among a nationally representative cohort of patients with PE at higher risk for mortality, CDT was associated with similar ICH rates, increased all-cause bleeding, and lower short and intermediate-term mortality when compared with ST. The competing risks and benefits of CDT in real-world practice suggest the need for large-scale randomized clinical trials with appropriate comparator arms.
Collapse
Affiliation(s)
- Bram J Geller
- Department of Medicine, Division of Cardiovascular Medicine, Maine Medical Center, Portland, ME, USA.,Division of Cardiovascular Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Srinath Adusumalli
- Department of Medicine, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven C Pugliese
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Sameed Ahmed M Khatana
- Department of Medicine, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Ashwin Nathan
- Department of Medicine, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Ido Weinberg
- Department of Medicine, Division of Vascular Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Michael R Jaff
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Taisei Kobayashi
- Department of Medicine, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeremy A Mazurek
- Department of Medicine, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Sameer Khandhar
- Department of Medicine, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Lin Yang
- Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter W Groeneveld
- Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Jay S Giri
- Department of Medicine, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
39
|
Abstract
The development of pulmonary hypertension (PH) in patients with heart failure is associated with increased morbidity and mortality. In this article, the authors examine recent changes to the definition of PH in the setting of left heart disease (PH-LHD), and discuss its epidemiology, pathophysiology and prognosis. They also explore the complexities of diagnosing PH-LHD and the current evidence for the use of medical therapies, promising clinical trials and the role of left ventricular assist device and transplantation.
Collapse
Affiliation(s)
- Sriram D Rao
- Advanced Heart Failure/Transplantation Programme, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania Philadelphia, PA, US
| | - Srinath Adusumalli
- Department of Medicine, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania Philadelphia, PA, US
| | - Jeremy A Mazurek
- Advanced Heart Failure/Transplantation Programme, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania Philadelphia, PA, US.,Pulmonary Hypertension Programme, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania Philadelphia, PA, US
| |
Collapse
|
40
|
Zamani P, Proto EA, Mazurek JA, Prenner SB, Margulies KB, Townsend RR, Kelly DP, Arany Z, Poole DC, Wagner PD, Chirinos JA. Peripheral Determinants of Oxygen Utilization in Heart Failure With Preserved Ejection Fraction: Central Role of Adiposity. ACTA ACUST UNITED AC 2020; 5:211-225. [PMID: 32215346 PMCID: PMC7091498 DOI: 10.1016/j.jacbts.2020.01.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 12/27/2019] [Accepted: 01/02/2020] [Indexed: 01/04/2023]
Abstract
ΔAVo2 during exercise is a complex metric that incorporates into its calculation skeletal muscle blood flow and DmO2 across the skeletal muscle capillary membrane. Although ΔAVo2 was reduced in patients with HFpEF during both systemic and local (forearm) exercise, there was no difference in forearm DmO2 among subjects with HFpEF, those with hypertension, and healthy control subjects; therefore, abnormalities in forearm DmO2 cannot explain the reduced forearm ΔAVo2 seen in subjects with HFpEF. Local forearm exercise performance predicted about one-third of the variability in systemic aerobic capacity, demonstrating that peripheral factors are important in determining whole-body exercise tolerance. Degree of adiposity strongly correlated with ΔAVo2 during both local and whole-body exercise, suggesting that adipose tissue may play an active role in limiting exercise capacity in subjects with HFpEF.
The aim of this study was to determine the arteriovenous oxygen content difference (ΔAVo2) in adult subjects with and without heart failure with preserved ejection fraction (HFpEF) during systemic and forearm exercise. Subjects with HFpEF had reduced ΔAVo2. Forearm diffusional conductance for oxygen, a lumped conductance parameter that incorporates all impediments to the movement of oxygen from red blood cells in skeletal muscle capillaries into the mitochondria within myocytes, was estimated. Forearm diffusional conductance for oxygen was not different among adults with HFpEF, those with hypertension, and healthy control subjects; therefore, diffusional conductance cannot explain the reduced forearm ΔAVo2. Instead, adiposity was strongly associated with ΔAVo2, suggesting an active role for adipose tissue in reducing exercise capacity in patients with HFpEF.
Collapse
Key Words
- CO, cardiac output
- DEXA, dual-energy x-ray absorptiometry
- DmO2, skeletal muscle diffusional conductance for oxygen
- FIo2, fraction of inspired oxygen
- HFpEF
- HFpEF, heart failure with preserved ejection fraction
- MVC, maximal voluntary contraction force
- NT-proBNP, N-terminal pro–brain natriuretic peptide
- Po2, partial pressure of oxygen
- Vo2, oxygen consumption
- adiposity
- aerobic capacity
- exercise
- oxygen transport
- ΔAVo2, arteriovenous oxygen content difference
Collapse
Affiliation(s)
- Payman Zamani
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth A Proto
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy A Mazurek
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stuart B Prenner
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kenneth B Margulies
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Raymond R Townsend
- Division of Nephrology/Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel P Kelly
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zoltan Arany
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David C Poole
- Departments of Kinesiology, Anatomy, and Physiology, Kansas State University, Manhattan, Kansas
| | - Peter D Wagner
- Division of Pulmonary Medicine, University of California-San Diego, San Diego, California
| | - Julio A Chirinos
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
41
|
Prenner SB, Pillutla R, Yenigalla S, Gaddam S, Lee J, Obeid MJ, Ans AH, Jehangir Q, Kim J, Zamani P, Mazurek JA, Akers SR, Chirinos JA. Serum Albumin Is a Marker of Myocardial Fibrosis, Adverse Pulsatile Aortic Hemodynamics, and Prognosis in Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2020; 9:e014716. [PMID: 32009529 PMCID: PMC7033884 DOI: 10.1161/jaha.119.014716] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Data regarding the phenotypic correlates and prognostic value of albumin in heart failure with preserved ejection fraction (HFpEF) are scarce. The goal of the current study is to determine phenotypic correlates (myocardial hypertrophy, myocardial fibrosis, detailed pulsatile hemodynamics, and skeletal muscle mass) and prognostic implications of serum albumin in HFpEF. Methods and Results We studied 118 adults with HFpEF. All‐cause death or heart‐failure–related hospitalization was ascertained over a median follow‐up of 57.6 months. We measured left ventricular mass, myocardial extracellular volume, and axial muscle areas using magnetic resonance imaging. Pulsatile arterial hemodynamics were assessed with a combination of arterial tonometry and phase‐contrast magnetic resonance imaging. Subjects with lower serum albumin exhibited a higher body mass index, and a greater proportion of black ethnicity and diabetes mellitus. A low serum albumin was associated with higher myocardial extracellular volume (52.3 versus 57.4 versus 39.3 mL in lowest to highest albumin tertile, respectively; P=0.0023) and greater N‐terminal pro B‐type natriuretic peptide levels, but not with a higher myocardial cellular volume (123 versus 114 versus 102 mL; P=0.13). Lower serum albumin was also associated with an increased forward wave amplitude and markedly increased pulsatile power in the aorta. Serum albumin was a strong predictor of death or heart failure hospitalization even after adjustment for N‐terminal pro B‐type natriuretic peptide levels and the Meta‐Analysis Global Group in Chronic Heart Failure (MAGGIC) risk score (adjusted standardized hazard ratio=0.56; 95% CI=0.37–0.83; P<0.0001). Conclusions Serum albumin is associated with myocardial fibrosis, adverse pulsatile aortic hemodynamics, and prognosis in HFpEF. This readily available clinical biomarker can enhance risk stratification in HFpEF and identifies a subgroup with specific pathophysiological abnormalities.
Collapse
Affiliation(s)
- Stuart B Prenner
- Department of Medicine University of Pennsylvania Perelman School of Medicine Philadelphia PA.,Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA
| | - Raj Pillutla
- Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA
| | | | - Sowmya Gaddam
- Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA
| | - Jonathan Lee
- Department of Medicine University of Pennsylvania Perelman School of Medicine Philadelphia PA.,Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA
| | - Mary Jo Obeid
- Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA
| | - Armghan Haider Ans
- Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA
| | - Qasim Jehangir
- Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA
| | - Jessica Kim
- Department of Medicine University of Pennsylvania Perelman School of Medicine Philadelphia PA.,Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA
| | - Payman Zamani
- Department of Medicine University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Jeremy A Mazurek
- Department of Medicine University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Scott R Akers
- Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA
| | - Julio A Chirinos
- Department of Medicine University of Pennsylvania Perelman School of Medicine Philadelphia PA.,Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA.,Departments of Internal Medicine and Radiology Corporal Michael J. Crescenz VAMC Philadelphia PA
| |
Collapse
|
42
|
Bhattacharya PT, Bhattacharya ST, Hameed AMA, Chirinos JA, Chatterjee S, Giri JS, Kawut SM, Mazurek JA. National Estimates and Predictors for Pulmonary Hypertension Readmission Categorized by Age Group. J Card Fail 2019. [DOI: 10.1016/j.cardfail.2019.07.256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
43
|
Zhang R, Hanff TC, Zhang Y, Molina M, McLean RC, Mazurek JA, Tanna M, Ramo JE, Wald J, Atluri P, Acker M, Goldberg LR, Birati EY. Increased Heart Rate Responsiveness after Heart Transplant is Associated with Increased Peak Oxygen Consumption and Treadmill Time in CPET. J Card Fail 2019. [DOI: 10.1016/j.cardfail.2019.07.279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
44
|
Hanff TC, Zhang RS, Zhang Y, Molina M, McLean RC, Mazurek JA, Tanna M, Rame JE, Wald JW, Atluri P, Acker MA, Goldberg LR, Birati EY. Acute Cellular Rejection Early after Heart Transplantation Does Not Reduce Exercise Capacity in the First Year. J Card Fail 2019. [DOI: 10.1016/j.cardfail.2019.07.489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
45
|
Rao SD, Menachem JN, Birati EY, Mazurek JA. Pulmonary Hypertension in Advanced Heart Failure: Assessment and Management of the Failing RV and LV. Curr Heart Fail Rep 2019; 16:119-129. [DOI: 10.1007/s11897-019-00431-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
46
|
Bhattacharya PT, Troutman GS, Mao F, Fox AL, Tanna MS, Zamani P, Grandin EW, Menachem JN, Birati EY, Chirinos JA, Mazimba S, Smith KA, Kawut SM, Forfia PR, Vaidya A, Mazurek JA. Right ventricular outflow tract velocity time integral-to-pulmonary artery systolic pressure ratio: a non-invasive metric of pulmonary arterial compliance differs across the spectrum of pulmonary hypertension. Pulm Circ 2019; 9:2045894019841978. [PMID: 30880577 PMCID: PMC6540515 DOI: 10.1177/2045894019841978] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pulmonary arterial compliance (PAC), invasively assessed by the ratio of stroke
volume to pulmonary arterial (PA) pulse pressure, is a sensitive marker of right
ventricular (RV)-PA coupling that differs across the spectrum of pulmonary
hypertension (PH) and is predictive of outcomes. We assessed whether the
echocardiographically derived ratio of RV outflow tract velocity time integral
to PA systolic pressure (RVOT-VTI/PASP) (a) correlates with invasive PAC, (b)
discriminates heart failure with preserved ejection-associated PH (HFpEF-PH)
from pulmonary arterial hypertension (PAH), and (c) is associated with
functional capacity. We performed a retrospective cohort study of patients with
PAH (n = 70) and HFpEF-PH (n = 86), which was further dichotomized by diastolic
pressure gradient (DPG) into isolated post-capillary PH (DPG < 7 mmHg;
Ipc-PH, n = 54), and combined post- and pre-capillary PH (DPG ≥ 7 mm Hg; Cpc-PH,
n = 32). Of the 156 patients, 146 had measurable RVOT-VTI or PASP and were
included in further analysis. RVOT-VTI/PASP correlated with invasive PAC overall
(ρ = 0.61, P < 0.001) and for the PAH (ρ = 0.38,
P = 0.002) and HFpEF-PH (ρ = 0.63,
P < 0.001) groups individually. RVOT-VTI/PASP differed
significantly across the PH spectrum (PAH: 0.13 [0.010–0.25] vs. Cpc-PH: 0.20
[0.12–0.25] vs. Ipc-PH: 0.35 [0.22–0.44]; P < 0.001),
distinguished HFpEF-PH from PAH (AUC = 0.72, 95% CI = 0.63–0.81) and Cpc-PH from
Ipc-PH (AUC = 0.78, 95% CI = 0.68–0.88), and remained independently predictive
of 6-min walk distance after multivariate analysis (standardized
β-coefficient = 27.7, 95% CI = 9.2–46.3; P = 0.004).
Echocardiographic RVOT-VTI/PASP is a novel non-invasive metric of PAC that
differs across the spectrum of PH. It distinguishes the degree of pre-capillary
disease within HFpEF-PH and is predictive of functional capacity.
Collapse
Affiliation(s)
- Priyanka T. Bhattacharya
- Center for Clinical Epidemiology and
Biostatistics, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA, USA
- Department of Medicine, Perelman School
of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory S. Troutman
- Sidney Kimmel Medical College at Thomas
Jefferson University, Philadelphia, PA, USA
| | - Frances Mao
- Department of Medicine, Perelman School
of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Arieh L. Fox
- Department of Medicine, Division of
Cardiovascular Medicine, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA
| | - Monique S. Tanna
- Department of Medicine, Division of
Cardiovascular Medicine, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA
| | - Payman Zamani
- Department of Medicine, Division of
Cardiovascular Medicine, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA
| | - E. Wilson Grandin
- Division of Cardiology, Richard A. and
Susan F. Smith Center for Cardiovascular Outcomes Research, Beth Israel Deaconess
Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jonathan N. Menachem
- Department of Medicine, Division of
Cardiovascular Medicine, Vanderbilt University, Nashville, TN, USA
| | - Edo Y. Birati
- Department of Medicine, Division of
Cardiovascular Medicine, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA
| | - Julio A. Chirinos
- Department of Medicine, Division of
Cardiovascular Medicine, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA
| | - Sula Mazimba
- University of Virginia Health System,
Charlottesville, VA, USA
| | - Kerri Akaya Smith
- Department of Medicine, Pulmonary
Hypertension Program, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA, USA
- Department of Medicine, Division of
Pulmonary, Allergy and Critical Care, Perelman School of Medicine at the University
of Pennsylvania, Philadelphia, PA, USA
| | - Steven M. Kawut
- Center for Clinical Epidemiology and
Biostatistics, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA, USA
- Department of Medicine, Pulmonary
Hypertension Program, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA, USA
- Department of Medicine, Division of
Pulmonary, Allergy and Critical Care, Perelman School of Medicine at the University
of Pennsylvania, Philadelphia, PA, USA
| | - Paul R. Forfia
- Pulmonary Hypertension, Right Heart
Failure and Pulmonary Thromboendarterectomy Program, Temple University Hospital,
Philadelphia, PA, USA
| | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart
Failure and Pulmonary Thromboendarterectomy Program, Temple University Hospital,
Philadelphia, PA, USA
| | - Jeremy A. Mazurek
- Department of Medicine, Division of
Cardiovascular Medicine, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Pulmonary
Hypertension Program, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA, USA
- Jeremy A. Mazurek, Division of
Cardiovascular Medicine Hospital of the University of Pennsylvania, Perelman
Center for Advanced Medicine, South Pavilion, 11th Floor, Suite 11-179, 3400
Civic Center Boulevard, Philadelphia, PA 19104, USA.
| |
Collapse
|
47
|
Bhattacharya PT, Bhattacharya ST, Hameed AA, Chirinos JA, Gimotty P, Chatterjee S, Giri JS, Kawut SM, Mazurek JA. Abstract 106: Predicting Pulmonary Hypertension Readmission Using Machine Learning Models. Circ Cardiovasc Qual Outcomes 2019. [DOI: 10.1161/hcq.12.suppl_1.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives:
Pulmonary hypertension (PH) is increasingly recognized but understudied. We sought to determine predictors of 30-day readmission after PH-related hospitalization using Driverless Artificial Intelligence (DAI) algorithm.
Methods:
We utilized the 2012-2014 Healthcare Cost and Utilization Project Nationwide Readmission Database (NRD) that accounts for weighted estimates of roughly 35 million discharges in the United States. Adult patients with primary ICD-9-CM diagnosis codes of 416.0 and 416.8 for primary and secondary PH with an index admission and any readmission within 30-days of the index event were identified. We assessed predictors of all cause 30-day readmission from clinical, hospital and 29 AHRQ comorbidity measures using predictive modeling to provide interpretable risk factors globally at population level and locally associated with each discharge. The risk prediction model was developed using DAI algorithm and results compared to models based on LIME GLM, Random Forest, and Decision Tree. Overall model performance was assessed using concordance statistic.
Results:
Data from patients with 14,659 admissions and 2797 30-day readmissions were used to train the model. After data processing, the final model included 3674 variables. The Random Forest model had the best performance with c-statistic of 0.70 and surrogate models compared at AUCs of 0.51(Decision Tree), 0.62 (LIME) and (DAI) 0.59. Global features that mainly important to the overall prediction of DAI model were deficiency anemia, APR-DRG severity risk, APR-DRG mortality risk, renal failure and CHF.
Conclusion:
Using predictive models with high predictive power, interpretable risk factors and prediction accuracy may enable health care systems to accurately target high-risk PH patients and prevent recurrent readmissions.
Collapse
Affiliation(s)
- Priyanka T Bhattacharya
- Hosp of Univ of Pennsylvania, Univ of Pennsylvania Perelman Sch of Medicine, Philadelphia, PA
| | | | - Asif A Hameed
- Mercy Catholic Med Cntr, Drexel Univ College of Medicine, Philadelphia, PA
| | - Julio A Chirinos
- Hosp of Univ of Pennsylvania, Univ of Pennsylvania Perelman Sch of Medicine, Philadelphia, PA
| | - Phyllis Gimotty
- Univ of Pennsylvania Perelman Sch of Medicine, Philadelphia, PA
| | - Saurav Chatterjee
- Hoffman Heart Institute, St Francis Hosp of the Univ of Connecticut, Hartford, CT
| | - Jay S Giri
- Hosp of Univ of Pennsylvania, Univ of Pennsylvania Perelman Sch of Medicine, Philadelphia, PA
| | - Steve M Kawut
- Hosp of Univ of Pennsylvania, Univ of Pennsylvania Perelman Sch of Medicine, Philadelphia, PA
| | - Jeremy A Mazurek
- Hosp of Univ of Pennsylvania, Univ of Pennsylvania Perelman Sch of Medicine, Philadelphia, PA
| |
Collapse
|
48
|
Kiely DG, Levin DL, Hassoun PM, Ivy D, Jone PN, Bwika J, Kawut SM, Lordan J, Lungu A, Mazurek JA, Moledina S, Olschewski H, Peacock AJ, Puri G, Rahaghi FN, Schafer M, Schiebler M, Screaton N, Tawhai M, van Beek EJ, Vonk-Noordegraaf A, Vandepool R, Wort SJ, Zhao L, Wild JM, Vogel-Claussen J, Swift AJ. EXPRESS: Statement on imaging and pulmonary hypertension from the Pulmonary Vascular Research Institute (PVRI). Pulm Circ 2019; 9:2045894019841990. [PMID: 30880632 PMCID: PMC6732869 DOI: 10.1177/2045894019841990] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 03/01/2019] [Indexed: 01/08/2023] Open
Abstract
Pulmonary hypertension (PH) is highly heterogeneous and despite treatment advances it remains a life-shortening condition. There have been significant advances in imaging technologies, but despite evidence of their potential clinical utility, practice remains variable, dependent in part on imaging availability and expertise. This statement summarizes current and emerging imaging modalities and their potential role in the diagnosis and assessment of suspected PH. It also includes a review of commonly encountered clinical and radiological scenarios, and imaging and modeling-based biomarkers. An expert panel was formed including clinicians, radiologists, imaging scientists, and computational modelers. Section editors generated a series of summary statements based on a review of the literature and professional experience and, following consensus review, a diagnostic algorithm and 55 statements were agreed. The diagnostic algorithm and summary statements emphasize the key role and added value of imaging in the diagnosis and assessment of PH and highlight areas requiring further research.
Collapse
Affiliation(s)
- David G. Kiely
- Sheffield Pulmonary Vascular Disease
Unit, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and
Cardiovascular Disease and Insigneo Institute, University of Sheffield, Sheffield,
UK
| | - David L. Levin
- Department of Radiology, Mayo Clinic,
Rochester, MN, USA
| | - Paul M. Hassoun
- Department of Medicine John Hopkins
University, Baltimore, MD, USA
| | - Dunbar Ivy
- Paediatric Cardiology, Children’s
Hospital, University of Colorado School of Medicine, Denver, CO, USA
| | - Pei-Ni Jone
- Paediatric Cardiology, Children’s
Hospital, University of Colorado School of Medicine, Denver, CO, USA
| | | | - Steven M. Kawut
- Department of Medicine, Perelman School
of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jim Lordan
- Freeman Hospital, Newcastle Upon Tyne,
Newcastle, UK
| | - Angela Lungu
- Technical University of Cluj-Napoca,
Cluj-Napoca, Romania
| | - Jeremy A. Mazurek
- Division of Cardiovascular Medicine,
Hospital
of the University of Pennsylvania,
Philadelphia, PA, USA
| | | | - Horst Olschewski
- Division of Pulmonology, Ludwig
Boltzmann Institute Lung Vascular Research, Graz, Austria
| | - Andrew J. Peacock
- Scottish Pulmonary Vascular Disease,
Unit, University of Glasgow, Glasgow, UK
| | - G.D. Puri
- Department of Anaesthesiology and
Intensive Care, Post Graduate Institute of Medical Education and Research,
Chandigarh, India
| | - Farbod N. Rahaghi
- Brigham and Women’s Hospital, Harvard
Medical School, Boston, MA, USA
| | - Michal Schafer
- Paediatric Cardiology, Children’s
Hospital, University of Colorado School of Medicine, Denver, CO, USA
| | - Mark Schiebler
- Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Merryn Tawhai
- Auckland Bioengineering Institute,
Auckland, New Zealand
| | - Edwin J.R. van Beek
- Edinburgh Imaging, Queens Medical
Research Institute, University of Edinburgh, Edinburgh, UK
| | | | - Rebecca Vandepool
- University of Arizona, Division of
Translational and Regenerative Medicine, Tucson, AZ, USA
| | - Stephen J. Wort
- Royal Brompton Hospital, London,
UK
- Imperial College, London, UK
| | | | - Jim M. Wild
- Department of Infection, Immunity and
Cardiovascular Disease and Insigneo Institute, University of Sheffield, Sheffield,
UK
- Academic Department of Radiology,
University of Sheffield, Sheffield, UK
| | - Jens Vogel-Claussen
- Institute of diagnostic and
Interventional Radiology, Medical Hospital Hannover, Hannover, Germany
| | - Andrew J. Swift
- Department of Infection, Immunity and
Cardiovascular Disease and Insigneo Institute, University of Sheffield, Sheffield,
UK
- Academic Department of Radiology,
University of Sheffield, Sheffield, UK
| |
Collapse
|
49
|
Menachem JN, Reza N, Mazurek JA, Burstein D, Birati EY, Fox A, Kim YY, Molina M, Partington SL, Tanna M, Tobin L, Wald J, Goldberg LR. Cardiopulmonary Exercise Testing-A Valuable Tool, Not Gatekeeper When Referring Patients With Adult Congenital Heart Disease for Transplant Evaluation. World J Pediatr Congenit Heart Surg 2019; 10:286-291. [PMID: 30832541 DOI: 10.1177/2150135118825263] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Treatment of patients with adult congenital heart disease (ACHD) with advanced therapies including heart transplant (HT) is often delayed due to paucity of objective prognostic markers for the severity of heart failure (HF). While the utility of Cardiopulmonary Exercise Testing (CPET) in non-ACHD patients has been well-defined as it relates to prognosis, CPET for this purpose in ACHD is still under investigation. METHODS We performed a retrospective cohort study of 20 consecutive patients with ACHD who underwent HT between March 2010 and February 2016. Only 12 of 20 patients underwent CPET prior to transplantation. Demographics, standard measures of CPET interpretation, and 30-day and 1-year post transplantation outcomes were collected. RESULTS Patient Characteristics. Twenty patients with ACHD were transplanted at a median of 40 years of age (range: 23-57 years). Of the 12 patients who underwent CPET, 4 had undergone Fontan procedures, 4 had tetralogy of Fallot, 3 had d-transposition of the great arteries, and 1 had Ebstein anomaly. Thirty-day and one-year survival was 100%. All tests included in the analysis had a peak respiratory quotient _1.0. The median peak oxygen consumption per unit time (_VO2) for all diagnoses was 18.2 mL/kg/min (46% predicted), ranging from 12.2 to 22.6. CONCLUSION There is a paucity of data to support best practices for patients with ACHD requiring transplantation. While it cannot be proven based on available data, it could be inferred that outcomes would have been worse or perhaps life sustaining options unavailable if providers delayed referral because of the lack of attainment of CPET-specific thresholds.
Collapse
Affiliation(s)
- Jonathan N Menachem
- 1 Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nosheen Reza
- 2 Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jeremy A Mazurek
- 2 Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Danielle Burstein
- 3 Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Edo Y Birati
- 2 Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Arieh Fox
- 4 Division of Cardiology, Mount Sinai Medical Center, New York, NY, USA
| | - Yuli Y Kim
- 2 Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Maria Molina
- 2 Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Sara L Partington
- 2 Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Monique Tanna
- 2 Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Lynda Tobin
- 2 Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joyce Wald
- 2 Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Lee R Goldberg
- 2 Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
50
|
Ruth BK, Bilchick KC, Mysore MM, Mwansa H, Harding WC, Kwon Y, Kennedy JLW, Mazurek JA, Mihalek AD, Smith LA, Mejia-Lopez E, Parker AM, Welch TS, Mazimba S. Increased Pulmonary-Systemic Pulse Pressure Ratio Is Associated With Increased Mortality in Group 1 Pulmonary Hypertension. Heart Lung Circ 2018; 28:1059-1066. [PMID: 30006114 DOI: 10.1016/j.hlc.2018.05.199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 03/14/2018] [Accepted: 05/29/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is characterised by remodelling of the pulmonary vasculature leading to right ventricular (RV) failure. The failing RV, through interventricular uncoupling, deleteriously impacts the left ventricle and overall cardiac efficiency. We hypothesised that the ratio of the pulmonary artery pulse pressure to the systemic pulse pressure ("pulmonary-systemic pulse pressure ratio", or PS-PPR) would be associated with mortality in PAH. METHODS We conducted a retrospective analysis of 262 patients in the National Institute of Health Primary Pulmonary Hypertension Registry (NIH-PPH). We evaluated the association between the PS-PPR and mortality after adjustment for the Pulmonary Hypertension Connection (PHC) risk equation. RESULTS Among 262 patients (mean age 37.5±15.8years, 62.2% female), median PS-PPR was 1.04 (IQR 0.79-1.30). In the Cox proportional hazards regression model, each one unit increase in the PS-PPR was associated with more than a two-fold increase in mortality during follow-up (HR 2.06, 95% CI 1.40-3.02, p=0.0002), and this association of PS-PPR with mortality remained significant in the multivariable Cox model adjusted for the PHC risk equation, mean pulmonary artery pressure, and body mass index (BMI) (adjusted HR 1.81, 95% CI 1.13-2.88, p=0.01). Furthermore, PS-PPR in the upper quartile (>1.30) versus quartiles 1-3 was associated with a 68% increase in mortality after adjustment for these same covariates (adjusted HR 1.68, 95% CI 1.13-2.50, p=0.01). CONCLUSIONS Pulmonary-systemic pulse pressure ratio, a marker of biventricular efficiency, is associated with survival in PAH even after adjustment for the PHC risk equation. Further studies are needed on the wider applications of PS-PPR in PAH patients.
Collapse
Affiliation(s)
- Benjamin K Ruth
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Kenneth C Bilchick
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Manu M Mysore
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Hunter Mwansa
- St Vincent Charity Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - William C Harding
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Younghoon Kwon
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Jamie L W Kennedy
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Jeremy A Mazurek
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew D Mihalek
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - LaVone A Smith
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Eliany Mejia-Lopez
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Alex M Parker
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Timothy S Welch
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA; Cardiology Service Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Sula Mazimba
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA.
| |
Collapse
|