1
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Wald JW, Bennett M, Chou J, Pal JD, Ravichandran A, Echols MR, Masser KS, Sheikh FH, Sayer G. Access to durable LVAD therapy for patients with limited social support: Surveying program-specific approaches. J Heart Lung Transplant 2024; 43:996-998. [PMID: 38342158 DOI: 10.1016/j.healun.2024.02.001] [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: 09/17/2023] [Revised: 01/30/2024] [Accepted: 02/04/2024] [Indexed: 02/13/2024] Open
Abstract
Racial and ethnic disparities in provision of left ventricular assist device (LVAD) therapy have been identified. These disparities may be at least partially related to socioeconomic factors, including social support networks and financial constraints. This study aimed to identify specific barriers, and variations in institutional approaches, to the provision of equitable care to underserved populations. A survey was administered to 237 LVAD program personnel, including physicians, LVAD coordinators, and social workers, at more than 100 LVAD centers across 7 countries. Three fourths of respondents reported that their program required a support person to live with the LVAD patient for some period of time following implantation. In addition, 31% of respondents reported that patients with the inability to pay for medications are turned down at their program. The most significant barriers to successful LVAD implantation were lack of social support, lack of insurance, and lack of timely referral. The most consistently identified supports needed from the hospital system for success in underserved populations were the provision of a solution for patient transportation to and from hospital visits and the provision of financial support. This survey highlights the challenges facing LVAD programs that care for underserved patient populations and sets the stage for specific interventions aimed at reducing disparities in access to care.
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Affiliation(s)
- Joyce W Wald
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mosi Bennett
- Allina Health Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Jiling Chou
- MedStar Health Research Institute, Hyattsville, Maryland
| | - Jay D Pal
- Division of Cardiothoracic Surgery, University of Washington, Seattle, Washington
| | | | - Melvin R Echols
- Division of Cardiovascular Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | | | - Farooq H Sheikh
- Department of Cardiology, MedStar Heart and Vascular Institute, Georgetown University, Washington, District of Columbia
| | - Gabriel Sayer
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York.
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2
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Cevasco M, Shin M, Cohen W, Helmers MR, Weingarten N, Rekhtman D, Wald JW, Iyengar A. Impella 5.5 as a bridge to heart transplantation: Waitlist outcomes in the United States. Clin Transplant 2023; 37:e15066. [PMID: 37392194 DOI: 10.1111/ctr.15066] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 02/17/2023] [Revised: 05/24/2023] [Accepted: 06/20/2023] [Indexed: 07/03/2023]
Abstract
OBJECTIVES The 2018 United Network for Organ Sharing allocation policy change has led to a significant increase in the use of mechanical circulatory support devices in patients listed for orthotopic heart transplantation. However, there has been a paucity of data regarding the newest generation Impella 5.5, which received FDA approval in 2019. METHODS The United Network for Organ Sharing registry was queried for all adults awaiting orthotopic heart transplantation who received Impella 5.5 support during their listing period. Waitlist, device, and early post-transplant outcomes were assessed. RESULTS A total of 464 patients received Impella 5.5 support during their listing period with a median waitlist time of 19 days. Among them, 402 (87%) patients were ultimately transplanted, with 378 (81%) being directly bridged to transplant with the device. Waitlist death (7%) and clinical deterioration (5%) were the most common reasons for waitlist removal. Device complications and failure were uncommon (<5%). The most common post-transplant complication was acute kidney injury requiring dialysis (16%). Survival at 1-year post-transplant survival was 89.5%. CONCLUSION Since its approval, the Impella 5.5 has been increasingly used as a bridge to transplant. This analysis demonstrates robust waitlist and post-transplant outcomes with minimal device-related and postoperative complications.
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Affiliation(s)
- Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Max Shin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - William Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Noah Weingarten
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Rekhtman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joyce W Wald
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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3
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Reza N, Edwards JJ, Katcoff H, Mondal A, Griffis H, Rossano JW, Lin KY, Holzhauser HL, Wald JW, Owens AT, Cappola TP, Birati EY, Edelson JB. Sex Differences in Left Ventricular Assist Device-related Emergency Department Encounters in the United States. J Card Fail 2022; 28:1445-1455. [PMID: 35644307 PMCID: PMC10066657 DOI: 10.1016/j.cardfail.2022.05.005] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND There is a paucity of data regarding sex differences in the profiles and outcomes of ambulatory patients on left ventricular assist device (LVAD) support who present to the emergency department (ED). METHODS AND RESULTS We performed a retrospective analysis of 57,200 LVAD-related ED patient encounters from the 2010 to 2018 Nationwide Emergency Department Sample. International Classification of Diseases Clinical Modification, Ninth Revision and Tenth Revision, codes identified patients aged 18 years or older with LVADs and associated primary and comorbidity diagnoses. Clinical characteristics and outcomes were stratified by sex and compared. Multivariable logistic regression was used to evaluate predictors of hospital admission and death. Female patient encounters comprised 27.2% of ED visits and occurred at younger ages and more frequently with obesity and depression (all P < .01). There were no sex differences in presentation for device complication, stroke, infection, or heart failure (all P > .05); however, female patient encounters were more often respiratory- and genitourinary or gynecological related (both P < .01). After adjustment for age group, diabetes, depression, and hypertension, male patient encounters had a 38% increased odds of hospital admission (95% confidence interval 1.20-1.58), but there was no sex difference in the adjusted odds of death (odds ratio 1.11, 95% confidence interval 0.86-1.45). CONCLUSIONS Patient encounters of females on LVAD support have significantly different comorbidities and outcomes compared with males. Further inquiry into these sex differences is imperative to improve long-term outcomes.
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Affiliation(s)
- Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Jonathan J Edwards
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hannah Katcoff
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Antara Mondal
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Heather Griffis
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph W Rossano
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kimberly Y Lin
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - H Luise Holzhauser
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce W Wald
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anjali T Owens
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas P Cappola
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edo Y Birati
- The Lydia and Carol Kittner, Lea and Benjamin Davidai Division of Cardiovascular Medicine and Surgery, Poriya Medical Center, and Azrieli Faculty of Medicine, Bar-Ilan University, Israel
| | - Jonathan B Edelson
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute for Healthcare Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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4
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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.
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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
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Prince AJ, Domenico CM, Shore S, Urgo KA, Atluri P, Wald JW, Birati EY. Ventricular Assist Device Driveline Infection and Development of Intracranial Hemorrhage: A Case Series. ASAIO J 2021; 67:e198-e200. [PMID: 33741789 DOI: 10.1097/mat.0000000000001409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Durable left ventricular assist devices (LVAD) are frequently complicated by driveline infection. The objective of this case series was to examine whether an association exists between driveline infection and intracranial hemorrhage. This retrospective case series included patients at a single tertiary care hospital on durable LVAD support who developed intracranial hemorrhage. Physical examination data, vital signs, and laboratory markers of sepsis including blood cultures and imaging of driveline sites were reviewed. A total of nine patients were included in the case series. At the time of hemorrhagic event, five patients had active driveline infection, and five patients were found to be bacteremic. All bacteremic patients were found to have supratherapeutic INR at the time of presentation. Although five patients experienced subarachnoid hemorrhage, only one patient was found to have a cerebral aneurysm. This case series highlights a possible association between LVAD driveline infection and intracranial hemorrhage, and the need for further research to better understand the pathophysiology driving this association.
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Affiliation(s)
- Adam J Prince
- From the Department of Internal Medicine, Lenox Hill Hospital, New York City, New York
| | - Christopher M Domenico
- Department of Medicine, Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Supriya Shore
- Department of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Kimberly A Urgo
- Department of Medicine, Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce W Wald
- Department of Medicine, Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edo Y Birati
- Department of Medicine, Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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6
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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.
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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
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7
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Emamaullee J, Zaidi AN, Schiano T, Kahn J, Valentino PL, Hofer RE, Taner T, Wald JW, Olthoff K, Bucuvalas J, Fischer R. Fontan-Associated Liver Disease: Screening, Management, and Transplant Considerations. Circulation 2020; 142:591-604. [PMID: 32776846 PMCID: PMC7422927 DOI: 10.1161/circulationaha.120.045597] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [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] [Indexed: 02/06/2023]
Abstract
Surgical innovation and multidisciplinary management have allowed children born with univentricular physiology congenital heart disease to survive into adulthood. An estimated global population of 70 000 patients have undergone the Fontan procedure and are alive today, most of whom are <25 years of age. Several unexpected consequences of the Fontan circulation include Fontan-associated liver disease. Surveillance biopsies have demonstrated that virtually 100% of these patients develop clinically silent fibrosis by adolescence. As they mature, there are increasing reports of combined heart-liver transplantation resulting from advanced liver disease, including bridging fibrosis, cirrhosis, and hepatocellular carcinoma, in this population. In the absence of a transplantation option, these young patients face a poor quality of life and overall survival. Acknowledging that there are no consensus guidelines for diagnosing and monitoring Fontan-associated liver disease or when to consider heart transplantation versus combined heart-liver transplantation in these patients, a multidisciplinary working group reviewed the literature surrounding Fontan-associated liver disease, with a specific focus on considerations for transplantation.
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Affiliation(s)
- Juliet Emamaullee
- Liver Transplant Center, Children’s Hospital-Los Angeles, Los Angeles, CA
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Ali N. Zaidi
- Mount Sinai Cardiovascular Institute & The Children’s Heart Center, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Thomas Schiano
- Division of Hepatology, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jeff Kahn
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of USC, Los Angeles, CA
| | - Pamela L. Valentino
- Section of Gastroenterology and Hepatology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Ryan E. Hofer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Timucin Taner
- Departments of Surgery and Immunology, Mayo Clinic, Rochester, MN
| | - Joyce W. Wald
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kim Olthoff
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - John Bucuvalas
- Division of Pediatric Hepatology, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryan Fischer
- Department of Gastroenterology, Liver Care Center, Children’s Mercy Kansas City, Kansas City, MO
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8
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Singh R, Domenico C, Rao SD, Urgo K, Prenner SB, Wald JW, Atluri P, Birati EY. Letter to Editor Reply: Therapeutic Strategy for Coronavirus Disease 2019 in Patients on Durable Left Ventricular Assist Device Support. J Card Fail 2020; 26:480-481. [PMID: 32405231 PMCID: PMC7217795 DOI: 10.1016/j.cardfail.2020.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/06/2020] [Indexed: 12/03/2022]
Affiliation(s)
- Rajat Singh
- Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher Domenico
- Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sriram D Rao
- Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kimberly Urgo
- Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stuart B Prenner
- Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce W Wald
- Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edo Y Birati
- Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Magruder JT, Suzuki Y, Sperry A, Vasquez CR, Smood B, Grimm JC, Atluri P, Bermudez C, Acker MA, Wald JW, Cantu E, Cevasco M. Multiorgan procurement is associated with a survival benefit after heart transplantation. Clin Transplant 2020; 34:e13901. [PMID: 32400887 DOI: 10.1111/ctr.13901] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/28/2020] [Accepted: 05/06/2020] [Indexed: 11/28/2022]
Abstract
We assessed the impact of donor multiorgan procurement on survival following orthotopic heart transplantation (OHT). From the UNOS STAR database, we included all adult (≥18 Y) heart transplants (OHT) performed since 2000 and used donor IDs to determine how many other organs were procured from the same donor as the recipient's heart allograft (regardless of recipient). The Kaplan-Meier survival functions and risk-adjusted Cox proportional hazards regression models were computed to assess the association of multiorgan procurement with post-heart transplantation mortality. We included 40 336 OHT patients. Including the heart, the median number of donor organs procured was 3 (IQR, 3-4). Heart donors underwent liver procurement in 89.7%; kidney(s) in 98.1% (single 95%, bilateral 5%); lung(s) in 38.0% (single 28%, bilateral 72%); pancreas in 10.4%; and intestine in 1.6%. Following risk adjustment across 16 recipient- and donor-specific variables, an increasing number of organs procured were independently associated with reduced post-OHT mortality (HR 0.98, 95% CI 0.96-0.99, P = .025). Though no significant associations were found examining specific organ types, double lung procurement trended toward a protective effect (HR 0.96, 0.92-1.01, P = .086), with counts of non-lung organs procured still bordering on significance (HR 0.97, 95% CI 0.95-1.00, P = .067). These results likely reflect improved multiorgan donor quality.
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Affiliation(s)
- Jonathan Trent Magruder
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yoshikazu Suzuki
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alexandra Sperry
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Charles R Vasquez
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Benjamin Smood
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua C Grimm
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christian Bermudez
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael A Acker
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joyce W Wald
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Edward Cantu
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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10
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Singh R, Domenico C, Rao SD, Urgo K, Prenner SB, Wald JW, Atluri P, Birati EY. Novel Coronavirus Disease 2019 in a Patient on Durable Left Ventricular Assist Device Support. J Card Fail 2020; 26:438-439. [PMID: 32305569 PMCID: PMC7162774 DOI: 10.1016/j.cardfail.2020.04.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 04/09/2020] [Accepted: 04/13/2020] [Indexed: 12/26/2022]
Affiliation(s)
- Rajat Singh
- Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Christopher Domenico
- Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sriram D Rao
- Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kimberly Urgo
- Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stuart B Prenner
- Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Joyce W Wald
- Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Pavan Atluri
- Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Edo Y Birati
- Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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11
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Riegel B, Hanlon AL, Coe NB, Hirschman KB, Thomas G, Stawnychy M, Wald JW, Bowles KH. Health coaching to improve self-care of informal caregivers of adults with chronic heart failure - iCare4Me: Study protocol for a randomized controlled trial. Contemp Clin Trials 2019; 85:105845. [PMID: 31499227 DOI: 10.1016/j.cct.2019.105845] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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] [Received: 06/18/2019] [Revised: 08/23/2019] [Accepted: 09/04/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Persons with chronic heart failure are living longer. These patients typically live in the community and are cared for at home by informal caregivers. These caregivers are an understudied and stressed group. METHODS We are conducting a two-arm, randomized controlled trial of 250 caregivers of persons with chronic heart failure to evaluate the efficacy of a health coaching intervention. A consecutive sample of participants is being enrolled from both clinic and hospital settings at a single institution affiliated with a large medical center in the northeastern US. Both the intervention and control groups receive tablets programmed to provide standardized health information. In addition, the intervention group receives 10 live coaching sessions delivered virtually by health coaches using the tablets. The intervention is evaluated at 6-months, with self-care as the primary outcome. Cost-effectiveness of the intervention is evaluated at 12-months. We are also enrolling heart failure patients (dyads) whenever possible to explore the effect of caregiver outcomes (self-care, stress, coping, health status) on heart failure patient outcomes (number of hospitalizations and days in the hospital) at 12-months. DISCUSSION We expect the proposed study to require 5 years for completion. If shown to be efficacious and cost-effective, our virtual health coaching intervention can easily be scaled to. support millions of caregivers worldwide.
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Affiliation(s)
| | | | - Norma B Coe
- University of Pennsylvania, United States of America
| | | | - Gladys Thomas
- University of Pennsylvania, United States of America
| | | | - Joyce W Wald
- Hospital of the University of Pennsylvania, United States of America
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12
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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]
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13
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Riegel B, Lee S, Hill J, Daus M, Baah FO, Wald JW, Knafl GJ. Patterns of adherence to diuretics, dietary sodium and fluid intake recommendations in adults with heart failure. Heart Lung 2019; 48:179-185. [PMID: 30638609 DOI: 10.1016/j.hrtlng.2018.12.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 12/20/2018] [Accepted: 12/21/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Three behaviors advocated to minimize fluid-related hospitalizations in patients with heart failure (HF) are restricted sodium and fluid intake and consistent oral diuretic use. Adherence to behaviors intended to decrease risk of hospitalization is believed to vary over time, but surprisingly little research has addressed patterns of adherence in HF patients. OBJECTIVE To describe patterns over time of 3 recommended self-care behaviors (i.e., diet, fluid intake, and diuretic dosing) in adults with HF and to determine how time and behavior influenced adherence rates. METHODS We enrolled 24 adults hospitalized for a HF exacerbation and discharged on a loop diuretic into a descriptive, longitudinal pilot study. Over 3-months, diuretic use was measured using electronic event monitoring, and participants were telephoned regularly to assess sodium and fluid intake. Data were summarized for each 2-week intervals. RESULTS The overall adherence rates were 42.4% for low sodium diet, 96.4% for fluid restriction, and 84.7% for the diuretic regimen. Early after hospital discharge, medication adherence was the highest, and dietary adherence was the lowest, but adherence to diet and diuretic use decreased significantly over time. CONCLUSION Although participants were just discharged from the hospital after an acute exacerbation of HF, all three behavioral patterns decreased markedly over the 3-month follow-up period.
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Affiliation(s)
- Barbara Riegel
- School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, 19104-4217 PA, USA.
| | - Solim Lee
- School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, 19104-4217 PA, USA
| | - Julia Hill
- Family Nurse Practitioner, North End Waterfront Health, Boston, MA, USA
| | - Marguerite Daus
- School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, 19104-4217 PA, USA
| | - Foster Osei Baah
- School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, 19104-4217 PA, USA
| | - Joyce W Wald
- Advanced heart failure and transplant program, university of Pennsylvania, Philadelphia, PA, USA
| | - George J Knafl
- School of Nursing, University of North Carolina, Chapel Hill, NC, USA
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14
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Kilic A, Chen CW, Gaffey AC, Wald JW, Acker MA, Atluri P. Preoperative renal dysfunction does not affect outcomes of left ventricular assist device implantation. J Thorac Cardiovasc Surg 2018; 156:1093-1101.e1. [PMID: 30017440 DOI: 10.1016/j.jtcvs.2017.12.044] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 10/19/2017] [Accepted: 12/09/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Selection criteria for durable left ventricular assist device (LVAD) implantation remain unclear. One such criterion is renal function. In this study we evaluated outcomes of LVAD implantation in patients with preoperative renal dysfunction. METHODS Patients with implanted LVADs as destination therapy (DT) or bridge to transplantation (BTT) at a single institution between 2006 and 2015 were included. Primary stratification was according to pre-implantation glomerular filtration rate (GFR): >60 mL/min versus <60 mL/min or dialysis dependence. The primary outcome was post-LVAD implantation overall survival. RESULTS Two hundred thirty-eight patients underwent LVAD implantation during the study period as DT (60%; n = 142) or BTT (40%; n = 96). Reduced GFR was present in 56% (n = 132), with 8% (n = 18) being dialysis-dependent. Normal versus reduced GFR cohorts were well matched except for a higher incidence of coronary artery disease in the patients with reduced GFR (61% vs 48%; P = .04). Mean follow-up was 13.5 ± 17.0 months. Unadjusted and risk-adjusted survival at 1, 3, 6, and 12 months after LVAD implantation were similar between the cohorts for DT and BTT. Rates of transplantation were comparable in BTT patients (61% normal vs 53% reduced GFR; P = .43). Recovery of renal function to a GFR >60 mL/min occurred in 43% (n = 17) and 57% (n = 42) of patients with reduced GFR in the BTT and DT cohorts, respectively, by 1 year post implantation. CONCLUSIONS Well selected patients with preexisting renal dysfunction can undergo LVAD implantation with acceptable outcomes. Approximately half of LVAD recipients with preimplantation renal dysfunction will recover normal renal function within the first postoperative year. Renal dysfunction alone should not serve as an absolute contraindication to LVAD therapy.
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Affiliation(s)
- Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Carol W Chen
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Ann C Gaffey
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Joyce W Wald
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pa
| | - Michael A Acker
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Pavan Atluri
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa.
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15
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Abstract
PURPOSE OF REVIEW We aim to summarize the effect of cancer therapy-related cardiotoxicity on the development of left ventricular (LV) dysfunction. RECENT FINDINGS We discuss commonly used cancer therapeutics that have the potential for both acute and delayed cardiotoxicity. LV dysfunction from cancer therapies may be found by routine cardiac imaging prior to clinical manifestations of heart failure (HF) and we discuss the current multi-modality approaches for early detection of toxicity with the use of advanced echocardiographic parameters including strain techniques. Further, we discuss the role of biomarkers for detection of LV dysfunction from cancer therapies. Current approaches monitoring and treating LV dysfunction related to cancer therapy-related cardiotoxicity include addressing modifiable cardiovascular risk factors especially hypertension and early initiation of neurohormonal blockade (NHB) with disease-modifying beta-blockers and renin-angiotensin-aldosterone system (RAAS) inhibitors. Once LV dysfunction is identified, traditional ACC/AHA guideline-directed therapy is employed. Further, we highlight the use of advanced heart failure therapies including mechanical resynchronization devices, the use of durable ventricular assist devices, and cardiac transplantation as increasingly employed modalities for treatment of severe LV dysfunction and advanced heart failure in the cardio-oncology population. This review seeks to highlight the importance of early detection, treatment, and prevention of LV dysfunction from cancer therapy-related cardiotoxicity.
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Affiliation(s)
- Suparna C Clasen
- Cardio-oncology in the Division of Cardiology, Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, South Pavilion 11th Floor, Philadelphia, PA, 19104, USA.
| | - Joyce W Wald
- Advanced Heart Failure in the Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
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16
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Riegel B, Dickson VV, Lee CS, Daus M, Hill J, Irani E, Lee S, Wald JW, Moelter ST, Rathman L, Streur M, Baah FO, Ruppert L, Schwartz DR, Bove A. A mixed methods study of symptom perception in patients with chronic heart failure. Heart Lung 2018; 47:107-114. [PMID: 29304990 PMCID: PMC5857218 DOI: 10.1016/j.hrtlng.2017.11.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 10/31/2017] [Accepted: 11/05/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early heart failure (HF) symptoms are frequently unrecognized for reasons that are unclear. We explored symptom perception in patients with chronic HF. METHODS We enrolled 36 HF out-patients into a longitudinal sequential explanatory mixed methods study. We used objectively measured thoracic fluid accumulation and daily reports of signs and symptoms to evaluate accuracy of detected changes in fluid retention. Patterns of symptom interpretation and response were explored in telephone interviews conducted every 2 weeks for 3-months. RESULTS In this sample, 44% had a mismatch between objective and subjective fluid retention; younger persons were more likely to have mismatch. In interviews, two patterns were identified: those able to interpret and respond appropriately to symptoms were higher in decision-making skill and the quality of social support received. CONCLUSION Many HF patients were poor at interpreting and managing their symptoms. These results suggest a subgroup of patients to target for intervention.
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Affiliation(s)
- Barbara Riegel
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA.
| | | | - Christopher S Lee
- School of Nursing, Oregon Health & Sciences University, Portland, OR, USA
| | - Marguerite Daus
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia Hill
- Community Healthcare Network, New York, NY, USA
| | - Elliane Irani
- School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Solim Lee
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Joyce W Wald
- Heart Failure - Transplant Program, University of Pennsylvania, Philadelphia, PA, USA
| | - Stephen T Moelter
- Department of Behavioral and Social Sciences, University of the Sciences, Philadelphia, PA, USA
| | - Lisa Rathman
- The Heart Group of Lancaster General Health/PENN Medicine, Philadelphia, PA, USA
| | - Megan Streur
- School of Nursing, University of Washington, Seattle, Washington, USA
| | - Foster Osei Baah
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Linda Ruppert
- Department of Medicine, Section of Cardiology, Louis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Daniel R Schwartz
- Department of Medicine, Section of Cardiology, Louis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Alfred Bove
- Department of Medicine, Section of Cardiology, Louis Katz School of Medicine, Temple University, Philadelphia, PA, USA
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17
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Menachem JN, Golbus JR, Molina M, Mazurek JA, Hornsby N, Atluri P, Fuller S, Birati EY, Kim YY, Goldberg LR, Wald JW. Successful cardiac transplantation outcomes in patients with adult congenital heart disease. Heart 2017; 103:1449-1454. [DOI: 10.1136/heartjnl-2016-310933] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 01/13/2017] [Accepted: 02/15/2017] [Indexed: 11/03/2022] Open
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18
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McQuade CN, Mizus M, Wald JW, Goldberg L, Jessup M, Umscheid CA. Brain-Type Natriuretic Peptide and Amino-Terminal Pro-Brain-Type Natriuretic Peptide Discharge Thresholds for Acute Decompensated Heart Failure: A Systematic Review. Ann Intern Med 2017; 166:180-190. [PMID: 27894126 DOI: 10.7326/m16-1468] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [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: 11/22/2022] Open
Abstract
BACKGROUND Acute decompensated heart failure (ADHF) requiring hospitalization is associated with high postdischarge mortality and readmission rates. PURPOSE To examine the association between achieving predischarge natriuretic peptide (NP) thresholds and mortality and readmission rates in adults hospitalized for ADHF. DATA SOURCES Multiple databases from 1947 to October 2016 (English-language studies only). STUDY SELECTION Trials and observational studies that compared mortality and readmission outcomes between patients with ADHF achieving a specific predischarge NP goal and those not achieving the goal. DATA EXTRACTION Two investigators independently extracted study characteristics and assessed study risk of bias. One author graded the overall strength of evidence, with review by a second author. DATA SYNTHESIS One randomized trial, 3 quasi-experimental studies, and 40 observational studies were identified. The most commonly used thresholds were a brain-type NP (BNP) level of 250 pg/mL or less or an amino-terminal pro-brain-type NP (NT-proBNP) decrease of at least 30%. Achievement of absolute BNP thresholds reduced postdischarge all-cause mortality (7 of 8 studies) and the composite outcome of mortality and readmission (12 of 14 studies). Achievement of percentage-change BNP thresholds reduced the composite outcome (5 of 6 studies), and achievement of percentage-change NT-proBNP thresholds reduced all-cause and cardiovascular mortality (2 of 4 studies) and the composite outcome (9 of 9 studies). All findings were low-strength. The randomized trial, assessed as having high risk of bias, suggested that a predischarge decrease in NT-proBNP level was associated with lower risk for the composite outcome. Two quasi-experimental studies and 5 observational studies had low risk of bias. Low-risk-of-bias studies had outcome estimates similar in magnitude and direction to estimates from high-risk-of-bias studies. LIMITATION Most studies failed to adjust for critical confounders and had inadequate definition or assessment of exposures and outcomes. CONCLUSION Low-strength evidence suggests an association between achieving NP predischarge thresholds and reduced ADHF mortality and readmission. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Casey N McQuade
- From Perelman School of Medicine, University of Pennsylvania, and Penn Medicine Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Marisa Mizus
- From Perelman School of Medicine, University of Pennsylvania, and Penn Medicine Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Joyce W Wald
- From Perelman School of Medicine, University of Pennsylvania, and Penn Medicine Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Lee Goldberg
- From Perelman School of Medicine, University of Pennsylvania, and Penn Medicine Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Mariell Jessup
- From Perelman School of Medicine, University of Pennsylvania, and Penn Medicine Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Craig A Umscheid
- From Perelman School of Medicine, University of Pennsylvania, and Penn Medicine Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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19
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Reza N, Menachem JN, Molina M, Wald JW, Mazurek JA, Birati EY, Partington SL, Goldberg LR. Cardiopulmonary Exercise Testing in Adults with Congential Heart Disease Underestimates Diesease Deverity Prior to Cardiac Transplantation. J Card Fail 2016. [DOI: 10.1016/j.cardfail.2016.06.372] [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: 10/21/2022]
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20
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Abstract
The American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines consider angiotensin-converting enzyme (ACE) inhibitors as one of the mainstay therapies in the management of heart failure. The widespread use of ACE inhibitors has been associated with several notable adverse effects such as hyperkalemia and an increased serum creatinine. There are no previous reports of alopecia associated with lisinopril use; however, a few previous cases of alopecia associated with other ACE inhibitors exist. This report discusses a case of lisinopril-induced alopecia of a 53-year-old male presenting to our outpatient heart failure clinic with a chief complaint of a new onset of alopecia. Upon evaluation, it was suspected that the patient's alopecia was likely medication induced by lisinopril; therefore, lisinopril was discontinued and switched to an angiotensin receptor blocker (ARB), losartan potassium. Alopecia resolved in 4 weeks after the therapeutic intervention. Our report suggests that the patient likely experienced a medication-induced alopecia, which was successfully resolved through proper identification and removal of the causative agent. Causality assessment between lisinopril and alopecia was determined using the Naranjo Adverse Drug Reaction Probability Scale-a total score of 6 was achieved and thus identified the adverse drug reaction as probable. Clinicians should be aware of the possibility that lisinopril may be an offending agent in a patient with unexplained alopecia.
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Affiliation(s)
- Vivek Kataria
- 1 Philadelphia College of Pharmacy, University of the Sciences, Department of Pharmacy Practice and Administration, Philadelphia, PA, USA
| | - Hueyyoung Wang
- 1 Philadelphia College of Pharmacy, University of the Sciences, Department of Pharmacy Practice and Administration, Philadelphia, PA, USA
| | - Joyce W Wald
- 2 Hospital of the University of Pennsylvania, Perelman Center for Advanced Medicine, Heart Failure/Transplant Program, Philadelphia, PA, USA
| | - Yvonne L Phan
- 1 Philadelphia College of Pharmacy, University of the Sciences, Department of Pharmacy Practice and Administration, Philadelphia, PA, USA.,2 Hospital of the University of Pennsylvania, Perelman Center for Advanced Medicine, Heart Failure/Transplant Program, Philadelphia, PA, USA
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21
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Frank R, Lal P, Kearns J, Molina MR, Wald JW, Goldberg LR, Kamoun M. Correlation of Circulating Complement-Fixing Donor-Specific Antibodies Identified by the C1q Assay and Presence of C4d in Endomyocardial Biopsy Specimens. Am J Clin Pathol 2016; 145:62-8. [PMID: 26712872 DOI: 10.1093/ajcp/aqv016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Donor-specific antibodies (DSAs) are associated with increased cardiac graft loss. We applied a C1q solid-phase assay in parallel with the standard immunoglobulin G (IgG) single antigen bead (SAB) assay to examine the correlation of circulating complement-fixing donor-specific antibodies and the presence of C4d in endomyocardial biopsy (EMB) specimens. METHODS We retrospectively studied the relationship of C1q+ DSAs and C4d immunofluorescence (IF) in 49 EMB specimens from 44 heart transplant recipients who had concurrent EMB, C4d IF, and DSA measurements. We applied a C1q SAB in parallel with the standard IgG SAB assay to examine the DSA profiles in heart transplant patients posttransplant. RESULTS A better concordance is observed between C1q+ DSAs with C4d IF+ compared with IgG DSAs with C4d IF + (40% vs 24%, P = .02). However, the correlation of C1q DSAs with C4d IF is not statistically significant (P = .24). Importantly, C1q+ DSAs were observed in 16 of 17 cases with C4d IF+; 24 cases had circulating C1q+ DSAs without detectable C4d staining, suggesting that that the presence of C1q+ DSAs may precede the detection of C4d deposition in EMB specimens and/or the development of antibody-mediated rejection. CONCLUSIONS In this cohort of 44 patients, no significant correlation was observed between circulating C1q DSAs and C4d IF in EMB specimens. Additional studies are needed to further evaluate the association of C1q DSAs with EMB specimens and C4d staining.
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Affiliation(s)
- Renee Frank
- From the Department of Pathology and Laboratory Medicine
| | - Priti Lal
- From the Department of Pathology and Laboratory Medicine
| | - Jane Kearns
- From the Department of Pathology and Laboratory Medicine
| | - Maria R Molina
- Heart Failure and Cardiac Transplant Program, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA
| | - Joyce W Wald
- Heart Failure and Cardiac Transplant Program, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lee R Goldberg
- Heart Failure and Cardiac Transplant Program, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA
| | - Malek Kamoun
- From the Department of Pathology and Laboratory Medicine
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22
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McCarthy FH, McDermott KM, Kini V, Gutsche JT, Wald JW, Xie D, Szeto WY, Bermudez CA, Atluri P, Acker MA, Desai ND. Trends in U.S. Extracorporeal Membrane Oxygenation Use and Outcomes: 2002-2012. Semin Thorac Cardiovasc Surg 2015; 27:81-8. [PMID: 26686427 DOI: 10.1053/j.semtcvs.2015.07.005] [Citation(s) in RCA: 162] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2015] [Indexed: 01/22/2023]
Abstract
This study evaluates contemporary trends in the use and outcomes of adult patients undergoing extracorporeal membrane oxygenation (ECMO) in U.S. hospitals. All adult discharges in the Nationwide Inpatient Sample database during the years 2002-2012 that included ECMO were used to estimate the total number of U.S. ECMO hospitalizations (n = 12,407). Diagnostic codes were used to group patients by indication for ECMO use into postcardiotomy, heart transplant, lung transplant, cardiogenic shock, respiratory failure, and cardiopulmonary failure. A Mann-Kendall test was used to examine trends over time using standard statistical techniques for survey data. We found that ECMO use increased significantly from 2002-2012 (P = 0.003), whereas in-hospital mortality rate fluctuated without a significant difference in trend over time. No significant trend was observed in overall ECMO use from 2002-2007, but the use did demonstrate a statistically significant increase from 2007-2012 (P = 0.0028). The highest in-hospital mortality rates were found in the postcardiotomy (57.2%) and respiratory failure (59.2%) groups. Lung and heart transplant groups had the lowest in-hospital mortality rates (44.10% and 45.31%, respectively). The proportion of ECMO use for postcardiotomy decreased from 56.9% in 2002 to 37.9% in 2012 (P = 0.026) and increased for cardiopulmonary failure from 3.9% to 11.1% (P = 0.026). We concluded that ECMO use in the United States increased between 2002 and 2012, driven primarily by increase in national ECMO use beginning in 2007. Mortality rates remained high but stable during this time period. Though there were shifts in relative ECMO use among patient groups, absolute ECMO use increased for all indications over the study period.
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Affiliation(s)
- Fenton H McCarthy
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Katherine M McDermott
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Vinay Kini
- Division of Cardiovascular Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Jacob T Gutsche
- Department of Anesthesia, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Joyce W Wald
- Division of Cardiovascular Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Dawei Xie
- Department of Biostatistics and Epidemiology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Christian A Bermudez
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Michael A Acker
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
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Frank R, Molina MR, Goldberg LR, Wald JW, Kamoun M, Lal P. Circulating donor-specific anti-human leukocyte antigen antibodies and complement C4d deposition are associated with the development of cardiac allograft vasculopathy. Am J Clin Pathol 2014; 142:809-15. [PMID: 25389335 DOI: 10.1309/ajcptlbeu5bq8shn] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [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: 10/24/2022] Open
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) continues to be a limiting factor in long-term survival of heart transplant recipients (HTRs). Pathophysiologic and immunologic factors affecting CAV are complex, and criteria for early diagnosis remain elusive. METHODS We performed a retrospective analysis of the relationship between donor-specific antibody (DSA), C4d immunofluorescence, and the development of CAV. RESULTS We evaluated 330 endomyocardial biopsy (EMB) specimens from 112 cardiac grafts. Twenty-four (21%) of 112 grafts developed CAV, and 18 (75%) of 24 were positive for C4d. Patients with DSA (n = 51) against human leukocyte antigen class I (n = 5), II (n = 26), or both (n = 20) developed CAV at a rate of 40%, 38%, and 20% and a mean time to CAV of 89, 47, and 25 months, respectively. Of 61 grafts without DSA, only 13% developed CAV, with a mean time to CAV of 116 months. CONCLUSIONS Compared with the general HTR population, patients with graft dysfunction and DSA or positive C4d on EMB show a statistically significant increased incidence of CAV and allograft failure, suggesting an antibody-mediated injury. The presence of pre- and posttransplant DSA, even in the absence of positive C4d immunofluorescence, may identify a group of HTRs at increased risk of developing CAV.
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Affiliation(s)
- Renee Frank
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Maria R. Molina
- Heart Failure and Cardiac Transplant Program, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia
| | - Lee R. Goldberg
- Heart Failure and Cardiac Transplant Program, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia
| | - Joyce W. Wald
- Heart Failure and Cardiac Transplant Program, Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia
| | - Malek Kamoun
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Priti Lal
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
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Kamoun M, Kearns J, Frank R, McCarro VR, Molina MR, Wald JW, Goldberg LR. 58-P. Hum Immunol 2013. [DOI: 10.1016/j.humimm.2013.08.133] [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: 11/17/2022]
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25
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Frank R, Molina MR, Wald JW, Goldberg LR, Kamoun M, Lal P. Correlation of circulating donor-specific anti-HLA antibodies and presence of C4d in endomyocardial biopsy with heart allograft outcomes: a single-center, retrospective study. J Heart Lung Transplant 2013; 32:410-7. [PMID: 23498162 DOI: 10.1016/j.healun.2012.12.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 12/06/2012] [Accepted: 12/18/2012] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Donor-specific antibodies (DSA) are associated with increased cardiac graft loss and cardiac vasculopathy (CAV). Detection of antibody-mediated rejection (AMR) relies on graft dysfunction, C4d immunofluorescence (IF) and DSA. METHODS We retrospectively studied the relationship of DSA, endomyocardial biopsy (EMB) and C4d IF to cardiac transplant outcomes. DSA were evaluated against HLA class I and II specificities, both pre- and post-transplant, using microbead-based assays. RESULTS Of 626 cardiac transplant patients, 109 with concurrent EMBs and C4d IF and DSA measurement were included in this study. In patients with and without DSA, CAV occurred in 31% and 13% and acute cellular rejection (ACR) in 100% and 84%, respectively. One hundred ten of 170 EMBs procured during episodes of graft dysfunction had concurrent DSA. In these patients, C4d IF correlated better with DSA to class I or both class I and II and less so in patients with DSA to class II. Graft failure (GF) rates of 40%, 29% and 58% with average times to GF of 33, 77 and 48 months were seen in patients with DSA to class I, II or both, respectively. CONCLUSIONS Patients with DSA to class I or to both class I and II showed a correlation with C4d IF and had higher GF rates compared to patients with DSA to only class II or no DSA; patients with DSA to class II remained at risk for CAV. Episodes of ACR and CAV, but not AMR, appeared to be more frequently associated with graft dysfunction in patients with circulating DSA.
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Affiliation(s)
- Renee Frank
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia 19104, USA
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26
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Wu RS, Gupta S, Brown RN, Yancy CW, Wald JW, Kaiser P, Kirklin NM, Patel PC, Markham DW, Drazner MH, Garry DJ, Mammen PPA. Clinical outcomes after cardiac transplantation in muscular dystrophy patients. J Heart Lung Transplant 2009; 29:432-8. [PMID: 19864165 DOI: 10.1016/j.healun.2009.08.030] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Revised: 08/30/2009] [Accepted: 08/31/2009] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Patients with muscular dystrophy are at risk of developing a dilated cardiomyopathy and can progress to advanced heart failure. At present, it is not known whether such patients can safely undergo cardiac transplantation. METHODS This was a retrospective review of the Cardiac Transplant Research Database, a multi-institutional registry of 29 transplant centers in the United States, from the years 1990 to 2005. The post-cardiac transplant outcomes of 29 patients with muscular dystrophy were compared with 275 non-muscular dystrophy patients with non-ischemic cardiomyopathy, matched for age, body mass index, gender, and race. RESULTS Becker's muscular dystrophy was present in 52% of the patients. Survival in the muscular dystrophy patients was similar to the controls at 1 year (89% vs 91%; p = 0.5) and at 5 years (83% vs 78%; p = 0.5). The differences in rates of cumulative infection, rejection, or allograft vasculopathy between the 2 groups were not significant (p > 0.5 for all comparisons). CONCLUSIONS Recognizing the limitations of the present investigation (ie, selection bias and data lacking in the functional capacity of the muscular dystrophy patients), the current study suggests that the clinical outcomes after cardiac transplantation in selected patients with muscular dystrophy are similar to those seen in age-matched patients with non-ischemic cardiomyopathy.
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Affiliation(s)
- Roland S Wu
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390-8573, USA
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27
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Chrzanowski SM, Wolfe C, Jessup ML, Acker MA, Wald JW, Forfia PR. Low Dose Nesiritide Infusion Leads to Rapid and Sustained Improvement in Renal Function in Patients with Acute Renal Failure Early Post Cardiac Transplantation. J Card Fail 2009. [DOI: 10.1016/j.cardfail.2009.06.287] [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]
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28
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Kashem A, Droogan MT, Santamore WP, Wald JW, Bove AA. Managing heart failure care using an internet-based telemedicine system. J Card Fail 2008; 14:121-6. [PMID: 18325458 DOI: 10.1016/j.cardfail.2007.10.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2007] [Revised: 09/15/2007] [Accepted: 10/12/2007] [Indexed: 12/19/2022]
Abstract
BACKGROUND Managing patients with heart failure (HF) is labor intensive, and follow-up is often inadequate to detect day-to-day changes that ultimately lead to decompensation. We tested the effect of an Internet-based telemedicine (T) system that provides frequent surveillance and increased communicate between HF patients and their provider on frequency of hospitalization in a cohort of patients with advanced HF. METHODS AND RESULTS HF patients in NYHA Class II-IV were randomized to usual care (UC, n = 24) or T (T plus UC, n = 24) and followed for 1 year. Office visits, emergency department visits, hospitalizations, telephone calls, and number of Internet communications were measured over the 1-year period. Left ventricular ejection fraction (EF) was assessed by echocardiography in both groups. For T, mean age was 53.2 +/- 2.0 years (72% male, 61% Caucasian, 39% African American). For UC, mean age was 54.1 +/- 2.6 years (76% male, 72% Caucasian, 14% African American, and 14% Hispanic). HF etiologies and EF were similar in both groups. During the 12-month period, UC had 74 total phone calls to the practice, whereas T had 88 telephone calls plus 1887 telemedicine data messages (6.5 messages/patient/month). ER visits were lower in the T group (T 5, UC 12; P < .05). Hospital admissions (T 24, C 40; P = .025) and total hospital days (T 84, UC 226 days; P < .005) were lower in T. Unscheduled clinic visits (T 13, UC 13; P = NS) and scheduled clinic visits (T 78, UC 94; P = NS) were similar in both groups. CONCLUSIONS Frequent monitoring and patient management using a telemedicine system may help to reduce hospitalizations, hospital days, and emergency department visits.
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Affiliation(s)
- Abul Kashem
- Section of Cardiology, Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA
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29
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Droogan MT, Kashem A, Santamore WP, Berger PT, Wald JW, Homko CJ, Bove AA. Additional Web-Based Telemedicine Monitoring of Heart Failure Patients Prevents ER and Re-Hospitalization. J Card Fail 2007. [DOI: 10.1016/j.cardfail.2007.06.562] [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]
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30
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Kashem A, Droogan MT, Santamore WP, Wald JW, Marble JF, Cross RC, Bove AA. Web-based Internet telemedicine management of patients with heart failure. Telemed J E Health 2006; 12:439-47. [PMID: 16942416 DOI: 10.1089/tmj.2006.12.439] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [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: 11/13/2022] Open
Abstract
An Internet-based store-and-retrieval telemedicine system to communicate between patients and their healthcare provider was tested. The system requires no specialized equipment, is Web-based, and allows frequent surveillance of the health status of the patients with heart failure (HF). Thirty six patients were recruited to evaluate a Web-based telemedicine system for reducing care encounters. Eighteen patients were randomized to the telemedicine arm (group T), and 18 were given usual clinical care (group C) in our HF center. Patients in group T reported three times weekly via a secure Internet site for telemedicine intervention. We studied patients with HF with New York Heart Association (NYHA) class 2 to 4 with hospitalization within past 6 months. Mean age was 56.1 +/- 12.6 years (66.7% male; 66.7% Caucasian, 27.8% African American, and 5.6% Hispanic). Mean ejection fraction (EF) was 23.9% +/- 17.6% in group T and 26.6% +/- 16.4% in group C. Over an 8-month period, unscheduled (group T-3; group C-5), and scheduled clinic visits (group T-11, group C-7) were similar (p = NS); one group T patient was transplanted, one group C patient died. Total hospital days were lower with group T (44 days) compared to group C (133 days), p < 0.05. An Internet-based telemedicine system was able to closely monitor patients with HF. Surveillance through Internet-based telemedicine resulted in less hospitalization compared to control patients. This system may be helpful in reducing the cost of HF patient care.
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Affiliation(s)
- Abul Kashem
- Section of Cardiology, Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA
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Kashem MA, Droogan MT, Santamore WP, Wald JW, Cross RC, Marble JF, Homko CF, Bove AA. 1-Year Follow-Up of Urban Underserved Congestive Heart Failure Patients through Web-Based Telemedicine Monitoring System. J Card Fail 2006. [DOI: 10.1016/j.cardfail.2006.06.245] [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: 11/28/2022]
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Wald JW, Burke JF, Kashem MA, O'Murchu B, Parker PE, Bove AA. Invasive Treatment of Cardiac Transplant Arteriopathy. J Card Fail 2006. [DOI: 10.1016/j.cardfail.2006.06.194] [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: 10/24/2022]
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33
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Leech SH, Lopez-Cepero M, LeFor WM, DiChiara L, Weston M, Furukawa S, Macha M, Singhal A, Wald JW, Nikolaidis LA, McClurken JB, Bove AA. Management of the sensitized cardiac recipient: the use of plasmapheresis and intravenous immunoglobulin. Clin Transplant 2006; 20:476-84. [PMID: 16842525 DOI: 10.1111/j.1399-0012.2006.00509.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Previously, we reported that the combination of plasmapheresis (PP) and intravenous immunoglobulin (IVIg) allow sensitized patients to undergo orthotopic heart transplantation (OHT), even across a positive crossmatch. In the current study, the effect of that combination, PP+IVIg, on survival of a larger group of such recipients is investigated. The latter group (I) consisted of 35 sensitized patients who received PP+IVIG together with standard immunosuppressive drugs. Rejection was seen in 11 patients, findings strongly suggestive of a vascular (humoral) being identified in five of those cases. Four deaths occurred, two of them in the immediate post-operative period, one after almost six months, and one after almost two yr post-OHT. Follow-up range 4.5 months to 7.8 yr post-OHT (average=1.1 yr). Patient survival was analyzed after generation of a Kaplan-Meier plot. Comparison with a control OHT group (II) given standard immunosuppressive drugs only (N=276) showed enhanced survival of group I (p=0.0414 by log-rank test). We conclude that the combination of PP and IVIG (i) is associated with declines in T- and B-percent-reactive antibody and in crossmatch positivity, and (ii) is very useful in the management of the sensitized cardiac patient undergoing OHT, often allowing a successful outcome to transplantation in the face of a positive crossmatch.
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Affiliation(s)
- S H Leech
- Department of Cardiology, Temple University Hospital and School of Medicine, Philadelphia, PA 19140, USA.
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