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Willeford A, Silva Enciso J. Transitioning disopyramide to mavacamten in obstructive hypertrophic cardiomyopathy: A case series and clinical guide. Pharmacotherapy 2023; 43:1397-1404. [PMID: 37688422 DOI: 10.1002/phar.2874] [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: 04/17/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is a genetic disorder for which first-line treatments for obstructive HCM (oHCM) include beta-blockers, non-dihydropyridine calcium channel blockers, and disopyramide for refractory cases. Mavacamten, a selective cardiac myosin inhibitor, is indicated for symptomatic oHCM to improve functional capacity and symptoms. Use of disopyramide and mavacamten together is not recommended due to concerns of additive negative inotropic effects. Transitioning from disopyramide to mavacamten may be preferred to avoid adverse effects and frequent administration, however, the best approach for making the transition has not been established. CASES We present a series of seven patients with oHCM who transitioned from disopyramide to mavacamten and underwent echocardiograms mandated by a Risk Evaluation and Mitigations Strategies program. Two methods were employed. The first approach, involving washout of disopyramide before starting mavacamten, resulted in worsening of heart failure symptoms in the first two cases. The second approach, involving tapering disopyramide when starting mavacamten, was successfully implemented in the last five cases, with no adverse effects or worsening of systolic dysfunction. CONCLUSION Our method of tapering disopyramide when starting mavacamten using a stepwise approach is feasible and safe. Our report fulfills an unmet need by serving as a guide for other clinicians who seek to transition their patients from disopyramide to mavacamten.
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Affiliation(s)
- Andrew Willeford
- UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, San Diego, California, USA
| | - Jorge Silva Enciso
- Division of Cardiology, Department of Medicine, University of California San Diego, San Diego, California, USA
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2
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Brubaker AL, Urey MA, Taj R, Parekh JR, Berumen J, Kearns M, Shah M, Khan A, Kono Y, Ajmera V, Barman P, Tran H, Adler ED, Silva Enciso J, Asimakopoulos F, Costello C, Bower R, Sanchez R, Pretorius V, Schnickel GT. Heart-liver-kidney transplantation for AL amyloidosis using normothermic recovery and storage from a donor following circulatory death: Short-term outcome in a first-in-world experience. Am J Transplant 2023; 23:291-293. [PMID: 36804136 DOI: 10.1016/j.ajt.2022.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 08/10/2022] [Revised: 10/18/2022] [Accepted: 11/10/2022] [Indexed: 01/13/2023]
Abstract
AL amyloidosis is a rare condition characterized by the overproduction of an unstable free light chain, protein misfolding and aggregation, and extracellular deposition that can progress to multiorgan involvement and failure. To our knowledge, this is the first worldwide report to describe triple organ transplantation for AL amyloidosis and triple organ transplantation using thoracoabdominal normothermic regional perfusion recovery with a donation from a circulatory death (DCD) donor. The recipient was a 40-year-old man with multiorgan AL amyloidosis with a terminal prognosis without multiorgan transplantation. An appropriate DCD donor was selected for sequential heart, liver, and kidney transplants via our center's thoracoabdominal normothermic regional perfusion pathway. The liver was additionally placed on an ex vivo normothermic machine perfusion, and the kidney was maintained on hypothermic machine perfusion while awaiting implantation. The heart transplant was completed first (cold ischemic time [CIT]: 131 minutes), followed by the liver transplant (CIT: 87 minutes, normothermic machine perfusion: 301 minutes). Kidney transplantation was performed the following day (CIT: 1833 minutes). He is 8 months posttransplant without evidence of heart, liver, or kidney graft dysfunction or rejection. This case highlights the feasibility of normothermic recovery and storage modalities for DCD donors, which can expand transplant opportunities for allografts previously not considered for multiorgan transplantations.
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Affiliation(s)
- Aleah L Brubaker
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, University of California San Diego, San Diego, California, USA.
| | - Marcus A Urey
- Department of Medicine, Division of Cardiology, University of California San Diego, San Diego, California, USA
| | - Raeda Taj
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, University of California San Diego, San Diego, California, USA
| | - Justin R Parekh
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, University of California San Diego, San Diego, California, USA
| | - Jennifer Berumen
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, University of California San Diego, San Diego, California, USA
| | - Mark Kearns
- Department of Surgery, Division of Cardiothoracic Surgery, University of California San Diego, San Diego, California, USA
| | - Mita Shah
- Department of Medicine, Division of Nephrology, University of California San Diego, San Diego, California, USA
| | - Adnan Khan
- Department of Medicine, Division of Nephrology, University of California San Diego, San Diego, California, USA
| | - Yuko Kono
- Department of Medicine, Division of Hepatology, University of California San Diego, San Diego, California, USA
| | - Veeral Ajmera
- Department of Medicine, Division of Hepatology, University of California San Diego, San Diego, California, USA
| | - Pranab Barman
- Department of Medicine, Division of Hepatology, University of California San Diego, San Diego, California, USA
| | - Hao Tran
- Department of Medicine, Division of Cardiology, University of California San Diego, San Diego, California, USA
| | - Eric D Adler
- Department of Medicine, Division of Cardiology, University of California San Diego, San Diego, California, USA
| | - Jorge Silva Enciso
- Department of Medicine, Division of Cardiology, University of California San Diego, San Diego, California, USA
| | - Fotis Asimakopoulos
- Department of Medicine, Division of Bone Marrow Transplant, University of California San Diego, San Diego, California, USA
| | - Caitlin Costello
- Department of Medicine, Division of Bone Marrow Transplant, University of California San Diego, San Diego, California, USA
| | - Richard Bower
- Department of Gastroenterology, Naval Medical Center San Diego, California, USA
| | - Ramon Sanchez
- Department of Anesthesia, University of California San Diego, San Diego, California, USA
| | - Victor Pretorius
- Department of Surgery, Division of Cardiothoracic Surgery, University of California San Diego, San Diego, California, USA
| | - Gabriel T Schnickel
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, University of California San Diego, San Diego, California, USA
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Keyt LK, Duran JM, Bui QM, Chen C, Miyamoto MI, Silva Enciso J, Tardiff JC, Adler ED. Thin filament cardiomyopathies: A review of genetics, disease mechanisms, and emerging therapeutics. Front Cardiovasc Med 2022; 9:972301. [PMID: 36158814 PMCID: PMC9489950 DOI: 10.3389/fcvm.2022.972301] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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: 06/18/2022] [Accepted: 07/28/2022] [Indexed: 11/17/2022] Open
Abstract
All muscle contraction occurs due to the cyclical interaction between sarcomeric thin and thick filament proteins within the myocyte. The thin filament consists of the proteins actin, tropomyosin, Troponin C, Troponin I, and Troponin T. Mutations in these proteins can result in various forms of cardiomyopathy, including hypertrophic, restrictive, and dilated phenotypes and account for as many as 30% of all cases of inherited cardiomyopathy. There is significant evidence that thin filament mutations contribute to dysregulation of Ca2+ within the sarcomere and may have a distinct pathomechanism of disease from cardiomyopathy associated with thick filament mutations. A number of distinct clinical findings appear to be correlated with thin-filament mutations: greater degrees of restrictive cardiomyopathy and relatively less left ventricular (LV) hypertrophy and LV outflow tract obstruction than that seen with thick filament mutations, increased morbidity associated with heart failure, increased arrhythmia burden and potentially higher mortality. Most therapies that improve outcomes in heart failure blunt the neurohormonal pathways involved in cardiac remodeling, while most therapies for hypertrophic cardiomyopathy involve use of negative inotropes to reduce LV hypertrophy or septal reduction therapies to reduce LV outflow tract obstruction. None of these therapies directly address the underlying sarcomeric dysfunction associated with thin-filament mutations. With mounting evidence that thin filament cardiomyopathies occur through a distinct mechanism, there is need for therapies targeting the unique, underlying mechanisms tailored for each patient depending on a given mutation.
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Affiliation(s)
- Lucas K. Keyt
- Department of Internal Medicine, University of California, San Diego, San Diego, CA, United States
| | - Jason M. Duran
- Department of Cardiology, University of California, San Diego, San Diego, CA, United States
| | - Quan M. Bui
- Department of Cardiology, University of California, San Diego, San Diego, CA, United States
| | - Chao Chen
- Department of Cardiology, University of California, San Diego, San Diego, CA, United States
| | | | - Jorge Silva Enciso
- Department of Cardiology, University of California, San Diego, San Diego, CA, United States
| | - Jil C. Tardiff
- Department of Medicine and Biomedical Engineering, University of Arizona, Tucson, AZ, United States
| | - Eric D. Adler
- Department of Cardiology, University of California, San Diego, San Diego, CA, United States
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Morris A, Shah KS, Enciso JS, Hsich E, Ibrahim NE, Page R, Yancy C. HFSA Position Statement The Impact of Healthcare Disparities on Patients with Heart Failure. J Card Fail 2022; 28:1169-1184. [PMID: 35595161 DOI: 10.1016/j.cardfail.2022.04.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [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: 02/11/2022] [Revised: 04/06/2022] [Accepted: 04/06/2022] [Indexed: 01/17/2023]
Abstract
Heart Failure (HF) remains a condition associated with high morbidity, mortality, and associated costs. Although the number of medical and device-based therapies available to treat HF are expanding at a remarkable rate, disparities in the risk for incident HF and treatments delivered to patients are also of growing concern. These disparities span across racial and ethnic groups, socioeconomic status, and apply across the spectrum of HF from Stage A to Stage D. The complexity of HF risk and treatment is further impacted by the number of patients who experience the downstream impact of social determinants of health. The purpose of this document is to highlight the known healthcare disparities that exist in the care of patients with HF, and to provide a context for how clinicians and researchers should assess both biologic and social determinants of HF risk in vulnerable populations. Furthermore, this document will provide a framework for future steps that can be utilized to help diminish inequalities in access and clinical outcomes over time, and offer solutions to help reduce disparities within HF care.
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Affiliation(s)
| | | | | | | | | | - Robert Page
- 1462 Clifton Road Suite 504, Atlanta GA 30322
| | - Clyde Yancy
- 1462 Clifton Road Suite 504, Atlanta GA 30322
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5
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Martinez AR, Enciso JS. Impact Of Left Atrial Volume Index On Syncope In Patients With Hypertrophic Cardiomyopathy. J Card Fail 2022. [DOI: 10.1016/j.cardfail.2022.03.267] [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: 11/26/2022]
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6
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Smith M, El-Said H, Pretorius V, Mendenhall M, Thomas T, Reeves RR, Silva Enciso J, Alshawabkeh L, Nigro J, Adler ED, Urey MA. Significance of Aortopulmonary Collaterals in a Single-Ventricle Patient Supported With a HeartMate 3. Circ Heart Fail 2020; 13:e006473. [PMID: 32248696 DOI: 10.1161/circheartfailure.119.006473] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Monica Smith
- Department of Transplant (M.S., M.M., T.T.), University of California San Diego
| | - Howaida El-Said
- Division of Pediatric Cardiology (H.E.-S.), University of California San Diego.,Division of Pediatric Cardiology (H.E.-S.), Rady Children's Hospital, San Diego, California
| | - Victor Pretorius
- Division of Cardiothoracic Surgery (V.P., J.N.), University of California San Diego
| | - Maggie Mendenhall
- Department of Transplant (M.S., M.M., T.T.), University of California San Diego
| | - Tracy Thomas
- Department of Transplant (M.S., M.M., T.T.), University of California San Diego
| | - Ryan R Reeves
- Division of Cardiovascular Medicine (R.R.R., J.S.E., L.A., E.D.A., M.A.U.), University of California San Diego
| | - Jorge Silva Enciso
- Division of Cardiovascular Medicine (R.R.R., J.S.E., L.A., E.D.A., M.A.U.), University of California San Diego
| | - Laith Alshawabkeh
- Division of Cardiovascular Medicine (R.R.R., J.S.E., L.A., E.D.A., M.A.U.), University of California San Diego
| | - John Nigro
- Division of Cardiothoracic Surgery (V.P., J.N.), University of California San Diego.,Division of Pediatric Surgery (J.N.), Rady Children's Hospital, San Diego, California
| | - Eric D Adler
- Division of Cardiovascular Medicine (R.R.R., J.S.E., L.A., E.D.A., M.A.U.), University of California San Diego
| | - Marcus A Urey
- Division of Cardiovascular Medicine (R.R.R., J.S.E., L.A., E.D.A., M.A.U.), University of California San Diego
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7
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Elkind J, Sobczyk J, Ostberg-Braun O, Silva Enciso J, Adler E, Morris GP. Factors influencing transfusion-associated HLA sensitization in patients bridged to heart transplantation using ventricular assist device. Clin Transplant 2019; 34:e13772. [PMID: 31845395 DOI: 10.1111/ctr.13772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 09/06/2019] [Revised: 11/29/2019] [Accepted: 12/09/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Bridging heart failure patients with mechanical ventricular assist devices (VAD) enables access to transplantation. However, VAD is associated with increased risk for anti-HLA antibodies associated with rejection of subsequent allografts. Factors determining alloantibody formation in these patients remain undefined. METHODS We performed a single-center retrospective cohort study of 164 patients undergoing heart transplantation from 2014 to 2017. Medical records including use of VAD, transfused blood products, anti-HLA antibody testing, crossmatch, and time to transplant were evaluated. RESULTS Patients received an average of 13.8 red blood cell and 1.9 single-donor platelet units associated with VAD. There was a 28.7% increase in the incidence of anti-HLA antibodies after VAD. Development of anti-HLA antibodies did not correlate with volume or type of blood products, but with pre-VAD HLA sensitization status; relative risk of new alloantibodies in patients with pre-VAD antibodies was 3.5-fold higher than those without prior antibodies (P = .008). Development of new anti-HLA antibodies was associated with an increased time to transplant (169 vs 330 days, P = .013). CONCLUSIONS Our findings indicate that the presence of anti-HLA antibodies pre-VAD was the most significant risk factor for developing additional antibodies post-VAD, suggesting that a subset of patients may be predisposed to alloantibody formation.
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Affiliation(s)
- Jae Elkind
- Department of Pathology, University of California, San Diego, La Jolla, CA, USA
| | - Juliana Sobczyk
- Department of Pathology, University of California, San Diego, La Jolla, CA, USA
| | - Oscar Ostberg-Braun
- Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Jorge Silva Enciso
- Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Eric Adler
- Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Gerald P Morris
- Department of Pathology, University of California, San Diego, La Jolla, CA, USA
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8
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Gernhofer YK, Braun OO, Brambatti M, Bui QM, Silva Enciso J, Greenberg BH, Adler E, Pretorius V. Which advanced heart failure therapy strategy is optimal for patients over 60 years old? J Cardiovasc Surg 2019; 60:251-258. [DOI: 10.23736/s0021-9509.18.10593-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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9
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Dan JM, Silva Enciso J, Lund LH, Aslam S. Heart transplantation outcomes for rheumatic heart disease: Analysis of international registry data. Clin Transplant 2018; 32:e13439. [PMID: 30383907 DOI: 10.1111/ctr.13439] [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: 07/18/2018] [Revised: 10/13/2018] [Accepted: 10/24/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Rheumatic heart disease (RHD), an autoimmune sequela of Group A streptococcal infection, is a chronic valvular disease affecting 32 million people worldwide, predominantly in developing nations. As the predisposition to autoimmune sequela still remains post transplantation, our primary objective was to assess if there were differences in mortality and rejection rates. METHODS AND RESULTS Using the International Society for Heart and Lung Transplantation (ISHLT) adult heart transplant registry, we identified 42 RHD patients who had undergone heart transplantation between 1988 and 2014. We matched the 42 RHD recipients by transplant year, age, and gender to 420 dilated cardiomyopathy (DCM) recipients. One-year mortality in the RHD group was 17.95% vs. 7.92% in the DCM group (P = 0.07). Survival was significantly reduced in the RHD group vs. the DCM group via Kaplan Meier curves (P = 0.04). In a multivariate model, RHD status (OR 3.19, 95% CI 1.15-8.83, P = 0.025) and serum creatinine (OR 1.41, 95% CI 1.09-1.82, P = 0.009) were associated with an increased odds of one-year mortality (P = 0.0013). CONCLUSIONS At one year post transplantation, RHD recipients had a significantly lower survival than DCM recipients. RHD status was also an independent predictor of mortality at 1 year post transplantation.
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Affiliation(s)
- Jennifer M Dan
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, California.,La Jolla Institute for Immunology, La Jolla, California
| | - Jorge Silva Enciso
- Division of Cardiovascular Medicine, University of California, San Diego, California
| | - Lars H Lund
- Departments of Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Solna, Sweden
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, California
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Brambatti M, Perna E, Ammirati E, Braun O, Cipriani M, Varrenti M, Mizeracki A, Enciso JS, Tran H, Bui Q, Stendardi W, Pretorius V, Russo C, Frigerio M, Adler E. Comparison of Outcomes and Adverse Events after Implantation of Left Ventricular Assist Device as Bridge to Transplantation in Centers in Italy and the Unites States. J Card Fail 2017. [DOI: 10.1016/j.cardfail.2017.07.380] [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: 11/26/2022]
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11
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Silva Enciso J, Greenberg B. Right ventricular failure after left ventricular assist device implant: 'towards finding common ground'. Eur J Heart Fail 2017; 19:947-949. [PMID: 28425168 DOI: 10.1002/ejhf.827] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 02/20/2017] [Accepted: 03/06/2017] [Indexed: 11/11/2022] Open
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12
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Bristow MR, Enciso JS, Gersh BJ, Grady C, Rice MM, Singh S, Sopko G, Boineau R, Rosenberg Y, Greenberg BH. Detection and Management of Geographic Disparities in the TOPCAT Trial: Lessons Learned and Derivative Recommendations. ACTA ACUST UNITED AC 2016; 1:180-189. [PMID: 27747305 PMCID: PMC5065247 DOI: 10.1016/j.jacbts.2016.03.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [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] [Indexed: 11/28/2022]
Abstract
TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial) was a multinational clinical trial of 3,445 heart failure with preserved ejection fraction patients that enrolled in 233 sites in 6 countries in North America, Eastern Europe, and South America. Patients with a heart failure hospitalization in the last 12 months or an elevated B-type natriuretic peptide were randomized to the mineralocorticoid receptor antagonist spironolactone versus placebo. Sites in Russia and the Republic of Georgia provided the majority of early enrollment, primarily based on the hospitalization criterion because B-type natriuretic peptide levels were initially unavailable there. With the emergence of country-specific aggregate event rate data indicating lower rates in Eastern Europe and differences in patient characteristics there, the Data Safety and Monitoring Board recommended relatively increasing enrollment in North America plus other corrective measures. Although final enrollment reflected the increased contribution from North America, a plurality of the final cohort came from Russia and Georgia (49% vs. 43% in North America). B-type natriuretic peptide measurements from Russia and Georgia, available later in the trial, suggested no or a mild level of heart failure consistent with low event rates. The primary results showed no significant spironolactone treatment effect overall (primary endpoint hazard ratio [HR]: 0.89; 95% confidence interval [CI]: 0.77 to 1.04), with a significant hazard ratio in North and South America (HR: 0.82; 95% CI: 0.69 to 0.98; p = 0.026) but not in Russia and Georgia (HR: 1.10; 95% CI: 0.79 to 1.51; interaction p = 0.12). This report describes the Data Safety and Monitoring Board’s detection and management recommendations for regional differences in patient characteristics in TOPCAT and suggests methods of surveillance and corrective actions that may be useful for future trials. (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial [TOPCAT]; NCT00094302)
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Affiliation(s)
- Michael R Bristow
- Cardiovascular Institute, University of Colorado, Boulder and Aurora, CO
| | | | | | - Christine Grady
- Department of Bioethics, National Institutes of Health Clinical Center, Bethesda, MD
| | | | | | - George Sopko
- Division of Cardiovascular Sciences, National Heart, Lung and Blood Institute, Bethesda, MD
| | - Robin Boineau
- Office of Clinical and Regulatory Affairs, National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, MD
| | - Yves Rosenberg
- Division of Cardiovascular Sciences, National Heart, Lung and Blood Institute, Bethesda, MD
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13
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Affiliation(s)
- Jorge Silva Enciso
- Advanced Heart Failure Program, University of California, San Diego, La Jolla, CA 92037-7411.
| | - Barry Greenberg
- Advanced Heart Failure Program, University of California, San Diego, La Jolla, CA 92037-7411
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Abstract
The heart failure epidemic has led to an increase in the number of patients with advanced heart failure, which is associated with high morbidity and mortality. Current therapies for advanced heart failure are limited to heart transplantation and mechanical circulatory support, with palliative care reserved for those ineligible to receive advanced therapies. Clinical trials of ventricular assist devices for patients with advanced heart failure demonstrate an improvement in survival and quality of life akin to heart transplantation. The Achilles heal of this therapy is the adverse event burden. Patient selection and multidisciplinary care are two of the strategies being used to improve long-term outcomes. Adjunct therapies in combination with left ventricular assist device therapy and advances in device technology in the near future may lessen the number of adverse events. This review summarizes the clinical outcomes, current challenges and future directions of left ventricular assist device therapy.
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15
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Tran HA, Silva Enciso J, Adler ED. Often talked about, seldom seen: promoting myocardial recovery with ventricular assist device. J Am Coll Cardiol 2014; 64:1613-4. [PMID: 25301466 DOI: 10.1016/j.jacc.2014.07.965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 07/01/2014] [Indexed: 11/19/2022]
Affiliation(s)
- Hao A Tran
- Department of Medicine, Division of Cardiology, University of California, San Diego, La Jolla, California
| | - Jorge Silva Enciso
- Department of Medicine, Division of Cardiology, University of California, San Diego, La Jolla, California
| | - Eric D Adler
- Department of Medicine, Division of Cardiology, University of California, San Diego, La Jolla, California.
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16
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Wever-Pinzon O, Bangalore S, Romero J, Enciso JS, Chaudhry FA. Inotropic contractile reserve can risk-stratify patients with HIV cardiomyopathy: a dobutamine stress echocardiography study. JACC Cardiovasc Imaging 2011; 4:1231-8. [PMID: 22172778 PMCID: PMC3595113 DOI: 10.1016/j.jcmg.2011.09.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [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: 04/01/2011] [Revised: 09/07/2011] [Accepted: 09/09/2011] [Indexed: 10/14/2022]
Abstract
OBJECTIVES The purpose of this study was to assess whether inotropic contractile reserve (ICR) during dobutamine stress echocardiography (DSE) could risk-stratify patients with human immunodeficiency virus (HIV) cardiomyopathy and predict improvement of left ventricular ejection fraction (LVEF). BACKGROUND HIV cardiomyopathy is an important cause of heart failure and death. ICR is associated with better survival and improvement of LVEF in patients with ischemic and nonischemic cardiomyopathies. However, the prognostic value of ICR in patients with HIV cardiomyopathy is unknown. METHODS Patients with HIV cardiomyopathy and a LVEF <45% who were referred for DSE were enrolled. ICR was evaluated by the delta wall motion score index (ΔWMSI), calculated as the difference between rest and peak WMSI. Patients were followed for cardiac death and change in LVEF on follow-up. RESULTS Sixty patients (75% men; age, 54 ± 9 years) with HIV cardiomyopathy (mean LVEF, 28 ± 11%) formed the study group. After 2.4 ± 2.1 years, 11 cardiac deaths occurred (event rate of 7.6%/year). A receiver-operating characteristic curve identified a ΔWMSI of 0.38 as an optimal cut point for the presence of ICR, with a specificity of 88% and a sensitivity of 73% for the prediction of cardiac death. On univariable analysis, the absence of ICR (hazard ratio: 6.6; 95% confidence interval: 1.93 to 22.62; p = 0.003) and New York Heart Association functional class IV (hazard ratio: 7.2; 95% confidence interval: 2.20 to 23.65; p = 0.001) were the only predictors of cardiac death. After 2.1 ± 1.8 years, 41 patients had a follow-up echocardiogram. LVEF improvement from baseline occurred in 23 patients (56%), more so in patients with ICR than without ICR. A ΔWMSI of 0.59 predicted improvement in the LVEF with a specificity of 78% and a sensitivity of 74%. CONCLUSIONS The presence of ICR during DSE can risk-stratify and predict subsequent improvement in LVEF in patients with HIV cardiomyopathy.
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Affiliation(s)
- Omar Wever-Pinzon
- St. Luke’s Roosevelt Hospital Center and Columbia University College of Physicians and Surgeons, New York, New York
| | | | - Jorge Romero
- St. Luke’s Roosevelt Hospital Center and Columbia University College of Physicians and Surgeons, New York, New York
| | - Jorge Silva Enciso
- St. Luke’s Roosevelt Hospital Center and Columbia University College of Physicians and Surgeons, New York, New York
| | - Farooq A. Chaudhry
- St. Luke’s Roosevelt Hospital Center and Columbia University College of Physicians and Surgeons, New York, New York
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Wever Pinzon O, Silva Enciso J, Romero J, Makani H, Fefer J, Gandhi V, Bangalore S, Chaudhry FA. Risk stratification and prognosis of human immunodeficiency virus-infected patients with known or suspected coronary artery disease referred for stress echocardiography. Circ Cardiovasc Imaging 2011; 4:363-70. [PMID: 21750273 PMCID: PMC3593109 DOI: 10.1161/circimaging.110.961060] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with human immunodeficiency virus (HIV) infection are at increased risk of accelerated coronary artery disease (CAD) and cardiovascular events. Stress echocardiography (SE) is routinely used for risk stratification and prognosis of patients with known or suspected CAD. The prognostic value of SE in this high-risk group is unknown. The purpose of this study was to evaluate the prognostic value of SE in HIV-infected patients with known or suspected CAD. METHODS AND RESULTS We evaluated 311 patients (age, 52 ± 9 years; 74% men; left ventricular ejection fraction, 54 ± 12%) with history of HIV, undergoing SE (56% dobutamine). Left ventricular wall motion was evaluated on a 16-segment model, 5-point scale. An abnormal SE was defined by a fixed (infarction), biphasic, or new (ischemia) wall motion abnormality on stress. Follow-up for cardiac death and myocardial infarction was obtained. Seventy-nine (26%) patients had an abnormal SE. After 2.9 ± 1.9 years, 17 confirmed myocardial infarction and 14 cardiac deaths occurred. SE risk-stratified patients into normal versus abnormal subgroups (event rate, 0.6% per year versus 11.8% per year; P < 0.0001). Both abnormal SE (hazard ratio, 28.2; 95% confidence interval, 6.2 to 128.0; P < 0.0001) and the presence of any ischemia on SE (hazard ratio, 3.4; 95% confidence interval, 1.3 to 8.6; P = 0.009) were independent predictors of cardiac events. On a forward conditional Cox proportional hazards regression model, SE provided incremental prognostic value over clinical, stress ECG, and resting echocardiographic variables (global χ(2) increased from 17.8 to 24.5 to 65 to 109, P < 0.05 across all groups). CONCLUSIONS SE can effectively risk-stratify and prognosticate patients with HIV. The presence of ischemia and scar during SE provides independent and incremental prognostic value over traditional variables. A normal SE response portends a benign prognosis even in this high-risk subset.
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Aziz EF, Kukin M, Javed F, Musat D, Nader A, Pratap B, Shah A, Enciso JS, Chaudhry FA, Herzog E. Right Ventricular Dysfunction is a Strong Predictor of Developing Atrial Fibrillation in Acutely Decompensated Heart Failure Patients, ACAP-HF Data Analysis. J Card Fail 2010; 16:827-34. [DOI: 10.1016/j.cardfail.2010.05.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Revised: 05/04/2010] [Accepted: 05/06/2010] [Indexed: 11/25/2022]
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pinzon OEW, Enciso JS, Romero J, Aziz E, Pudpud D, Chaudhry FA. INOTROPIC CONTRACTILE RESERVE CAN RISK STRATIFY AND PROGNOSTICATE PATIENTS WITH HIV CARDIOMYOPATHY: A DOBUTAMINE STRESS ECHO STUDY. J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)60908-4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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pinzon OEW, Enciso JS, Aziz E, Romero J, Cantales D, Chaudhry FA. ROLE OF STRESS ECHOCARDIOGRAPHY IN RISK STRATIFICATION AND PROGNOSIS OF PATIENTS WITH HIV. J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)60902-3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Makani HJ, Messerli FH, Di Giorgio C, Romero J, De Benedetti Zunino ME, Enciso JS. EFFECT OF RENIN ANGIOTENSIN SYSTEM (RAS) BLOCKADE ON CALCIUM ANTAGONIST ASSOCIATED PEDAL EDEMA. J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)60586-4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Makani HJ, Messerli FH, Korniyenko A, Romero J, De Benedetti Zunino ME, Enciso JS. DO ANGIOTENSIN RECEPTOR BLOCKERS INCREASE THE RISK OF ANGIOEDEMA? J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)60476-7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Makani HJ, De Benedetti Zunino ME, Di Giorgio C, Romero J, Kabbli G, Enciso JS, Messerli FH. PEDAL EDEMA ASSOCIATED WITH CALCIUM ANTAGONISTS - INCIDENCE AND WITHDRAWAL RATE. J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)60475-5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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