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Severino P, Mancone M, D'Amato A, Mariani MV, Prosperi S, Alunni Fegatelli D, Birtolo LI, Angotti D, Milanese A, Cerrato E, Maestrini V, Pizzi C, Foà A, Vestri A, Palazzuoli A, Vizza CD, Casale PN, Mather PJ, Fedele F. Heart failure 'the cancer of the heart': the prognostic role of the HLM score. ESC Heart Fail 2024; 11:390-399. [PMID: 38011913 PMCID: PMC10804198 DOI: 10.1002/ehf2.14594] [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: 08/01/2023] [Revised: 11/02/2023] [Accepted: 11/06/2023] [Indexed: 11/29/2023] Open
Abstract
AIMS The multi-systemic effects of heart failure (HF) resemble the spread observed during cancer. We propose a new score, named HLM, analogous to the TNM classification used in oncology, to assess the prognosis of HF. HLM refers to H: heart damage, L: lung involvement, and M: systemic multiorgan involvement. The aim was to compare the HLM score to the conventional New York Heart Association (NYHA) classification, American College of Cardiology/American Heart Association (ACC/AHA) stages, and left ventricular ejection fraction (LVEF), to assess the most accurate prognostic tool for HF patients. METHODS AND RESULTS We performed a multicentre, observational, prospective study of consecutive patients admitted for HF. Heart, lung, and other organ function parameters were collected. Each patient was classified according to the HLM score, NYHA classification, ACC/AHA stages, and LVEF assessed by transthoracic echocardiography. The follow-up period was 12 months. The primary endpoint was a composite of all-cause death and rehospitalization due to HF. A total of 1720 patients who completed the 12 month follow-up period have been enrolled in the study. 520 (30.2%) patients experienced the composite endpoint of all-cause death and rehospitalization due to HF. 540 (31.4%) patients were female. The mean age of the study population was 70.5 ± 12.9. The mean LVEF at admission was 42.5 ± 13%. Regarding the population distribution across the spectrum of HLM score stages, 373 (21.7%) patients were included in the HLM-1, 507 (29.5%) in the HLM-2, 587 (34.1%) in the HLM-3, and 253 (14.7%) in the HLM-4. HLM was the most accurate score to predict the primary endpoint at 12 months. The area under the receiver operating characteristic curve (AUC) was greater for the HLM score compared with the NYHA classification, ACC/AHA stages, or LVEF, regarding the composite endpoint (HLM = 0.645; NYHA = 0.580; ACC/AHA = 0.589; LVEF = 0.572). The AUC of the HLM score was significantly better compared with the LVEF (P = 0.002), ACC/AHA (P = 0.029), and NYHA (P = 0.009) AUC. CONCLUSIONS The HLM score has a greater prognostic power compared with the NYHA classification, ACC/AHA stages, and LVEF assessed by transthoracic echocardiography in terms of the composite endpoint of all-cause death and rehospitalization due to HF at 12 months of follow-up.
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Affiliation(s)
- Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular SciencesSapienza University of RomeViale del PoliclinicoRomeItaly
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular SciencesSapienza University of RomeViale del PoliclinicoRomeItaly
| | - Andrea D'Amato
- Department of Clinical, Internal, Anesthesiology and Cardiovascular SciencesSapienza University of RomeViale del PoliclinicoRomeItaly
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiology and Cardiovascular SciencesSapienza University of RomeViale del PoliclinicoRomeItaly
| | - Silvia Prosperi
- Department of Clinical, Internal, Anesthesiology and Cardiovascular SciencesSapienza University of RomeViale del PoliclinicoRomeItaly
| | | | - Lucia Ilaria Birtolo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular SciencesSapienza University of RomeViale del PoliclinicoRomeItaly
| | - Danilo Angotti
- Department of Clinical, Internal, Anesthesiology and Cardiovascular SciencesSapienza University of RomeViale del PoliclinicoRomeItaly
| | - Alberto Milanese
- Department of Public Health and Infectious DiseaseSapienza University of RomeRomeItaly
| | - Enrico Cerrato
- Interventional Cardiology UnitSan Luigi Gonzaga University Hospital, Orbassano and Rivoli Infermi HospitalRivoli (Turin)Italy
| | - Viviana Maestrini
- Department of Clinical, Internal, Anesthesiology and Cardiovascular SciencesSapienza University of RomeViale del PoliclinicoRomeItaly
| | - Carmine Pizzi
- Department of Experimental, Diagnostic and Specialty Medicine‐DIMESUniversity of Bologna, IRCCS Sant'Orsola‐Malpighi HospitalBolognaItaly
| | - Alberto Foà
- Department of Experimental, Diagnostic and Specialty Medicine‐DIMESUniversity of Bologna, IRCCS Sant'Orsola‐Malpighi HospitalBolognaItaly
| | - Annarita Vestri
- Department of Public Health and Infectious DiseaseSapienza University of RomeRomeItaly
| | - Alberto Palazzuoli
- Cardiovascular Diseases UnitLe Scotte Hospital, University of SienaSienaItaly
| | - Carmine Dario Vizza
- Department of Clinical, Internal, Anesthesiology and Cardiovascular SciencesSapienza University of RomeViale del PoliclinicoRomeItaly
| | - Paul N. Casale
- Department of Cardiology and Population Health SciencesWeill Cornell Medical CollegeNew YorkNYUSA
| | - Paul J. Mather
- Division of Cardiovascular MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
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McCaffrey JA, Dhakal BP, Nathan AS, Ortega-Legaspi J, Fiorilli PN, Mather PJ, Supple GE. Loss of Right Atrial Pacing Lead Capture Due to Myocardial Infarction Obscuring Diagnosis on Electrocardiogram. JACC Case Rep 2022; 4:890-894. [PMID: 35912331 PMCID: PMC9334149 DOI: 10.1016/j.jaccas.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/15/2022] [Accepted: 06/06/2022] [Indexed: 11/19/2022]
Abstract
Right coronary artery occlusion can lead to failure to capture from the right atrial pacing lead. In this case, acute infarction resulted in failure of the right atrial lead to capture and thus increased right ventricular pacing. The new ventricular pacing masked the diagnosis of acute myocardial infarction. (Level of Difficulty: Intermediate.)
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Affiliation(s)
- James A. McCaffrey
- Electrophysiology Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bishnu P. Dhakal
- Electrophysiology Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ashwin S. Nathan
- Interventional Cardiology Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Juan Ortega-Legaspi
- Advanced Heart Failure Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul N. Fiorilli
- Interventional Cardiology Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul J. Mather
- Advanced Heart Failure Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory E. Supple
- Electrophysiology Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Address for correspondence: Dr. Gregory E. Supple, Electrophysiology Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104, USA.
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3
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D’Amato A, Severino P, Mariani MV, Prosperi S, Fegatelli DA, Pucci M, Angotti D, Costi B, Cerrato E, Vestri A, Palazzuoli A, Casale PN, Mather PJ, Mancone M, Fedele F. HEART FAILURE AS THE CANCER OF THE HEART: THE PROMISING PROGNOSTIC TOOL OF TNMLIKE CLASSIFICATION. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)01375-4] [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: 11/28/2022]
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Abstract
Sodium-glucose cotransporter type 2 (SGLT2) inhibitors are a relatively new class of antihyperglycemic drug with salutary effects on glucose control, body weight, and blood pressure. Emerging evidence now indicates that these drugs may have a beneficial effect on outcomes in heart failure with reduced ejection fraction (HFrEF). Post-approval cardiovascular outcomes data for three of these agents (canagliflozin, empagliflozin, and dapagliflozin) showed an unexpected improvement in cardiovascular endpoints, including heart failure hospitalization and mortality, among patients with type 2 diabetes mellitus (T2DM) and established cardiovascular disease or risk factors. These studies were followed by a placebo controlled trial of dapagliflozin in patients with HFrEF both with and without T2DM, showing a reduction in all-cause mortality comparable to current guideline-directed HFrEF medical therapies such as angiotensin-converting enzyme inhibitors and beta-blockers. In this review, we discuss the current landscape of evidence, safety and adverse effects, and proposed mechanisms of action for use of these agents for patients with HFrEF. The United States (US) and European guidelines are reviewed, as are the current US federally approved indications for each SGLT2 inhibitor. Use of these agents in clinical practice may be limited by an uncertain insurance environment, especially in patients without T2DM. Finally, we discuss practical considerations for the cardiovascular clinician, including within-class differences of the SGLT2 inhibitors currently available on the US market (217/300).
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Affiliation(s)
- Michael V Genuardi
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul J Mather
- Perelman School of Medicine, University of Pennsylvania, 2 East Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
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5
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Zhang RS, Padegimas A, Murphy KM, Evans PT, Peters CJ, Domenico CM, Vidula MK, Mather PJ, Cevasco M, Cohen RB, Carver JR, O'Quinn RP. Treatment of corticosteroid refractory immune checkpoint inhibitor myocarditis with Infliximab: a case series. Cardiooncology 2021; 7:13. [PMID: 33785062 PMCID: PMC8008661 DOI: 10.1186/s40959-021-00095-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 02/07/2021] [Indexed: 12/22/2022]
Abstract
Background Glucocorticoid treatment remains the cornerstone of therapy for immune checkpoint inhibitor (ICI) myocarditis, but data supporting the use of additional immunotherapy for steroid refractory cases remains limited. We investigate the safety and efficacy of infliximab in patients with ICI myocarditis who are refractory to corticosteroids. Additionally, we highlight the importance of a multi-disciplinary approach in the care for these complex patients. Methods We retrospectively identified consecutive patients who developed ICI myocarditis at our institution between January 2017 and January 2020. Baseline characteristics, laboratory data and clinical outcomes were compared between patients who received infliximab and those who did not. Results Of a total of 11 patients who developed ICI myocarditis, 4 were treated with infliximab. Aside from age, there were no significant differences in baseline patient characteristics between the two groups including total number of ICI doses received and duration from initial ICI dose to onset of symptoms. The time to troponin normalization was 58 vs. 151.5 days (p = 0.25). The duration of prednisone taper was longer in the infliximab group (90 vs. 150 days p = 0.32). All patients survived initial hospital admission. Over a median follow-up period of 287 days, two of the 4 patients died from sepsis 2 and 3 months after initial treatment of their myocarditis; one of these patients was on a steroid taper and the other patient had just completed a steroid taper. Conclusions Infliximab, despite its black box warning in patients with heart failure, may be a safe and effective treatment for ICI myocarditis.
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Affiliation(s)
- Robert S Zhang
- Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA
| | - Allison Padegimas
- Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA.,Division of Cardiovascular Medicine, University of Pennsylvania, PA, Philadelphia, USA
| | - Kathleen M Murphy
- Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA.,Division of Infectious Disease, University of Pennsylvania, PA, Philadelphia, USA
| | - Peter T Evans
- Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA
| | - Carli J Peters
- Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA
| | | | - Mahesh K Vidula
- Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA.,Division of Cardiovascular Medicine, University of Pennsylvania, PA, Philadelphia, USA
| | - Paul J Mather
- Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA.,Division of Cardiovascular Medicine, University of Pennsylvania, PA, Philadelphia, USA
| | - Marisa Cevasco
- Department of Cardiothoracic Surgery, University of Pennsylvania, PA, Philadelphia, USA
| | - Roger B Cohen
- Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA.,Division of Hematology-Oncology, University of Pennsylvania, PA, Philadelphia, USA
| | - Joseph R Carver
- Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA.,Division of Cardiovascular Medicine, University of Pennsylvania, PA, Philadelphia, USA.,Division of Hematology-Oncology, University of Pennsylvania, PA, Philadelphia, USA
| | - Rupal P O'Quinn
- Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA. rupal.o'.,Division of Cardiovascular Medicine, University of Pennsylvania, PA, Philadelphia, USA. rupal.o'
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6
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Severino P, D'Amato A, Saglietto A, D'Ascenzo F, Marini C, Schiavone M, Ghionzoli N, Pirrotta F, Troiano F, Cannillo M, Mennuni M, Rognoni A, Rametta F, Galluzzo A, Agnes G, Infusino F, Pucci M, Lavalle C, Cacciotti L, Mather PJ, Grosso Marra W, Ugo F, Forleo G, Viecca M, Morici N, Patti G, De Ferrari GM, Palazzuoli A, Mancone M, Fedele F. Reduction in heart failure hospitalization rate during coronavirus disease 19 pandemic outbreak. ESC Heart Fail 2020; 7:4182-4188. [PMID: 33094929 PMCID: PMC7754919 DOI: 10.1002/ehf2.13043] [Citation(s) in RCA: 26] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/09/2020] [Accepted: 09/16/2020] [Indexed: 12/14/2022] Open
Abstract
AIMS The recent coronavirus disease 19 (COVID-19) pandemic outbreak forced the adoption of restraint measures, which modified the hospital admission patterns for several diseases. The aim of the study is to investigate the rate of hospital admissions for heart failure (HF) during the early days of the COVID-19 outbreak in Italy, compared with a corresponding period during the previous year and an earlier period during the same year. METHODS AND RESULTS We performed a retrospective analysis on HF admissions number at eight hospitals in Italy throughout the study period (21 February to 31 March 2020), compared with an inter-year period (21 February to 31 March 2019) and an intra-year period (1 January to 20 February 2020). The primary outcome was the overall rate of hospital admissions for HF. A total of 505 HF patients were included in this survey: 112 during the case period, 201 during intra-year period, and 192 during inter-year period. The mean admission rate during the case period was 2.80 admissions per day, significantly lower compared with intra-year period (3.94 admissions per day; incidence rate ratio, 0.71; 95% confidence interval [CI], 0.56-0.89; P = 0.0037), or with inter-year (4.92 admissions per day; incidence rate ratio, 0.57; 95% confidence interval, 0.45-0.72; P < 0.001). Patients admitted during study period were less frequently admitted in New York Heart Association (NYHA) Class II compared with inter-year period (P = 0.019). At covariance analysis NYHA class was significantly lower in patients admitted during inter-year control period, compared with patients admitted during case period (P = 0.014). CONCLUSIONS Admissions for HF were significantly reduced during the lockdown due to the COVID-19 pandemic in Italy.
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Affiliation(s)
- Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Andrea D'Amato
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Andrea Saglietto
- Division of Cardiology, AOU Città della Salute e della Scienza di Torino, Section of Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, AOU Città della Salute e della Scienza di Torino, Section of Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Claudia Marini
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco Schiavone
- Department of Cardiology, Luigi Sacco Hospital, Polo Universitario, Milan, Italy
| | - Nicolò Ghionzoli
- Cardiovascular Diseases Unit, Le Scotte Hospital, University of Siena, Siena, Italy
| | - Filippo Pirrotta
- Cardiovascular Diseases Unit, Le Scotte Hospital, University of Siena, Siena, Italy
| | | | | | | | | | | | | | - Gianluca Agnes
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Fabio Infusino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Mariateresa Pucci
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy.,Madre Giuseppina Vannini Hospital, Rome, Italy
| | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | | | - Paul J Mather
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Fabrizio Ugo
- Sant'Andrea di Vercelli Hospital, Vercelli, Italy
| | - Giovanni Forleo
- Department of Cardiology, Luigi Sacco Hospital, Polo Universitario, Milan, Italy
| | - Maurizio Viecca
- Department of Cardiology, Luigi Sacco Hospital, Polo Universitario, Milan, Italy
| | - Nuccia Morici
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giuseppe Patti
- AOU Maggiore della Carità, Novara, Italy.,Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Gaetano M De Ferrari
- Division of Cardiology, AOU Città della Salute e della Scienza di Torino, Section of Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Le Scotte Hospital, University of Siena, Siena, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
| | - Francesco Fedele
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy
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8
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Severino P, Mather PJ, Pucci M, D'Amato A, Mariani MV, Infusino F, Birtolo LI, Maestrini V, Mancone M, Fedele F. Advanced Heart Failure and End-Stage Heart Failure: Does a Difference Exist. Diagnostics (Basel) 2019; 9:diagnostics9040170. [PMID: 31683887 PMCID: PMC6963179 DOI: 10.3390/diagnostics9040170] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 12/16/2022] Open
Abstract
Advanced heart failure (AdHF) represents a challenging aspect of heart failure patients. Because of worsening clinical symptoms, high rates of re-hospitalization and mortality, AdHF represents an unstable condition where standard treatments are inadequate and additional interventions must be applied. A heart transplant is considered the optimal therapy for AdHF, but the great problem linked to the scarcity of organs and long waiting lists have led to the use of mechanical circulatory support with ventricular-assist device (VAD) as a destination therapy. VAD placement improves the prognosis, functional status, and quality of life of AdHF patients, with high rates of survival at 1 year, similar to transplant. However, the key element is to select the right patient at the right moment. The complete assessment must include a careful clinical evaluation, but also take into account psychosocial factors that are of crucial importance in the out-of-hospital management. It is important to distinguish between AdHF and end-stage HF, for which advanced therapy interventions would be unreasonable due to severe and irreversible organ damage and, instead, palliative care should be preferred to improve quality of life and relief of suffering. The correct selection of patients represents a great issue to solve, both ethically and economically.
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Affiliation(s)
- Paolo Severino
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Paul J Mather
- Department of Medicine, Division of Cardiology University of Pennsylvania, Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA.
| | - Mariateresa Pucci
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Andrea D'Amato
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Marco Valerio Mariani
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Fabio Infusino
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Lucia Ilaria Birtolo
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Viviana Maestrini
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Massimo Mancone
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
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9
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Ortega-Legaspi JM, Mather PJ, Farber JL. Giant Cell Myocarditis: Long Term Survival Following Left Ventricular Assist Device Implantation. J Card Fail 2018. [DOI: 10.1016/j.cardfail.2018.07.342] [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: 10/28/2022]
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10
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Affiliation(s)
- Hillary Johnston-Cox
- Department of Medicine, Division of Cardiology University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Paul J Mather
- Department of Medicine, Division of Cardiology University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
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11
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Hullmann JE, Mather PJ. Elevated Body Mass Index Is Not a Risk Factor for Adverse Outcomes Following Ventricular Assist Device Implantation. Prog Transplant 2018; 28:157-162. [PMID: 29558875 DOI: 10.1177/1526924818765817] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite ventricular assist devices (VADs) becoming more common in heart failure (HF) treatment, it is still uncertain which patients are more prone to complications. One potential risk factor is increased body mass index (BMI), which is known to increase both all-cause mortality and mortality from ischemic heart disease; however, the role of the BMI in predicting morbidity and mortality following device implantation is unclear. METHODS The study population for this single-institution retrospective chart review consisted of 136 patients with HF, who underwent VAD implantation between 2004 and 2015. Patients were divided into 2 groups based on their BMI: a nonobese group (18.5 < BMI < 30.0; n = 82) or an obese group (BMI >30.0; n = 54). These groups were compared at baseline and after implantation for survival, hospital readmission, and adverse events. RESULTS No significant difference was found in initial hospital length of stay, number or length of readmissions, or readmission diagnosis. At 1 year, rates of ongoing device support, orthotopic heart transplant (OHT), and death were not significantly different between groups ( P = .89, P = .90, and P = .70, respectively). Multivariate analysis did not identify obesity as an independent predictor of mortality ( P = .90); only biventricular assist device implantation was associated with decreased survival (hazard ratio [HR] = 5.90, P = .002). CONCLUSION Obesity in itself should not preclude the use of VAD support in patients with HF, as carefully selected obese patients were shown to have similar rates of hospital readmission, 1-year outcomes, and survival following device implantation compared to nonobese patients.
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Affiliation(s)
| | - Paul J Mather
- 2 Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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12
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Shore S, Mather PJ. Editorial commentary: Heart failure with preserved ejection fraction-Clinical syndrome with incomplete understanding. Trends Cardiovasc Med 2018; 28:401-402. [PMID: 29428158 DOI: 10.1016/j.tcm.2018.01.005] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 01/19/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Supriya Shore
- Department of Medicine, Cardiovascular Division, University of Pennsylvania, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Paul J Mather
- Department of Medicine, Cardiovascular Division, University of Pennsylvania, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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13
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Prenner SB, Mather PJ. Obesity and heart failure with preserved ejection fraction: A growing problem. Trends Cardiovasc Med 2017; 28:322-327. [PMID: 29305040 DOI: 10.1016/j.tcm.2017.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 11/07/2017] [Accepted: 12/04/2017] [Indexed: 01/09/2023]
Abstract
Heart Failure with Preserved Ejection Fraction (HFpEF) is increasing in prevalence due to the aging of the United States population as well as the current obesity epidemic. While obesity is very common in patients with HFpEF, obesity may represent a specific phenotype of HFpEF characterized by unique hemodynamics and structural abnormalities. Obesity induces a systemic inflammatory response that may contribute to myocardial fibrosis and endothelial dysfunction. The most obese patients continue to be excluded from HFpEF clinical trials, and thus ongoing research is needed to determine the role of pharmacologic and interventional approaches in this growing population.
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Affiliation(s)
- Stuart B Prenner
- Department of Medicine, Cardiovascular Division, University of Pennsylvania, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul J Mather
- Department of Medicine, Cardiovascular Division, University of Pennsylvania, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Sharma S, Mather PJ, Chowdhury A, Gupta S, Mukhtar U, Willes L, Whellan DJ, Malhotra A, Quan SF. Sleep Overnight Monitoring for Apnea in Patients Hospitalized with Heart Failure (SOMA-HF Study). J Clin Sleep Med 2017; 13:1185-1190. [PMID: 28859720 DOI: 10.5664/jcsm.6768] [Citation(s) in RCA: 19] [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] [Received: 03/15/2017] [Accepted: 07/05/2017] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Sleep-disordered breathing (SDB) is highly prevalent in hospitalized patients with congestive heart failure (CHF) and the condition is diagnosed and treated in only a minority of these patients. Portable monitoring (PM) is a screening option, but due to costs and the expertise required, many hospitals may find it impractical to implement. We sought to test the utility of an alternative approach for screening hospitalized CHF patients for SDB, high-resolution pulse oximetry (HRPO). METHODS We conducted a prospective controlled trial of 125 consecutive patients admitted to the hospital with CHF. Simultaneous PM and HRPO for a single night was performed. All but one patient were monitored on breathing room air. The HRPO-derived ODI (oxygen desaturation index) was compared with PM-derived respiratory event index (REI) using both receiver operator characteristic (ROC) curve analysis and a Bland-Altman plot. RESULTS Of 105 consecutive CHF patients with analyzable data, 61 (58%) were males with mean age of 64.9 ± 15.1 years and mean body mass index of 30.3 ± 8.3 kg/m2. Of the 105 patients, 10 (9.5%) had predominantly central sleep apnea (central events > 50% of the total events), although central events were noted in 42 (40%) of the patients. The ROC analysis showed an area under the curve of 0.89 for REI > 5 events/h. The Bland-Altman plot showed acceptable agreement with 95% limits of agreement between -28.5 to 33.7 events/h and little bias. CONCLUSIONS We conclude that high-resolution pulse oximetry is a simple and cost-effective screening tool for SDB in CHF patients admitted to the hospital. Such screening approaches may be valuable for large-scale implementation and for the optimal design of interventional trials.
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Affiliation(s)
- Sunil Sharma
- Einstein Medical Center, Philadelphia, Pennsylvania
| | - Paul J Mather
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Umer Mukhtar
- Einstein Medical Center, Philadelphia, Pennsylvania
| | | | | | | | - Stuart F Quan
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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15
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Whellan DJ, Stebbins A, Hernandez AF, Ezekowitz JA, McMurray JJ, Mather PJ, Hasselblad V, O'Connor CM. Dichotomous Relationship Between Age and 30-Day Death or Rehospitalization in Heart Failure Patients Admitted With Acute Decompensated Heart Failure: Results From the ASCEND-HF Trial. J Card Fail 2016; 22:409-16. [DOI: 10.1016/j.cardfail.2016.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 01/13/2016] [Accepted: 02/29/2016] [Indexed: 01/28/2023]
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16
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Blauwet LA, Delgado-Montero A, Ryo K, Marek JJ, Alharethi R, Mather PJ, Modi K, Sheppard R, Thohan V, Pisarcik J, McNamara DM, Gorcsan J. Right Ventricular Function in Peripartum Cardiomyopathy at Presentation Is Associated With Subsequent Left Ventricular Recovery and Clinical Outcomes. Circ Heart Fail 2016; 9:CIRCHEARTFAILURE.115.002756. [DOI: 10.1161/circheartfailure.115.002756] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [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: 10/12/2015] [Accepted: 04/08/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Lori A. Blauwet
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (L.A.B.); University of Pittsburgh, PA (A.D.-M., K.R., J.J.M., J.P., D.M.M., J.G.); Intermountain Medical Center, Murray, UT (R.A.); Thomas Jefferson University, Philadelphia, PA (P.J.M.); Louisiana State University Health Science Center, Shreveport, LA (K.M.); McGill University, Montreal, Canada (R.S.); and Aurora Healthcare, Milwaukee, Wisconsin (V.T.)
| | - Antonia Delgado-Montero
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (L.A.B.); University of Pittsburgh, PA (A.D.-M., K.R., J.J.M., J.P., D.M.M., J.G.); Intermountain Medical Center, Murray, UT (R.A.); Thomas Jefferson University, Philadelphia, PA (P.J.M.); Louisiana State University Health Science Center, Shreveport, LA (K.M.); McGill University, Montreal, Canada (R.S.); and Aurora Healthcare, Milwaukee, Wisconsin (V.T.)
| | - Keiko Ryo
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (L.A.B.); University of Pittsburgh, PA (A.D.-M., K.R., J.J.M., J.P., D.M.M., J.G.); Intermountain Medical Center, Murray, UT (R.A.); Thomas Jefferson University, Philadelphia, PA (P.J.M.); Louisiana State University Health Science Center, Shreveport, LA (K.M.); McGill University, Montreal, Canada (R.S.); and Aurora Healthcare, Milwaukee, Wisconsin (V.T.)
| | - Josef J. Marek
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (L.A.B.); University of Pittsburgh, PA (A.D.-M., K.R., J.J.M., J.P., D.M.M., J.G.); Intermountain Medical Center, Murray, UT (R.A.); Thomas Jefferson University, Philadelphia, PA (P.J.M.); Louisiana State University Health Science Center, Shreveport, LA (K.M.); McGill University, Montreal, Canada (R.S.); and Aurora Healthcare, Milwaukee, Wisconsin (V.T.)
| | - Rami Alharethi
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (L.A.B.); University of Pittsburgh, PA (A.D.-M., K.R., J.J.M., J.P., D.M.M., J.G.); Intermountain Medical Center, Murray, UT (R.A.); Thomas Jefferson University, Philadelphia, PA (P.J.M.); Louisiana State University Health Science Center, Shreveport, LA (K.M.); McGill University, Montreal, Canada (R.S.); and Aurora Healthcare, Milwaukee, Wisconsin (V.T.)
| | - Paul J. Mather
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (L.A.B.); University of Pittsburgh, PA (A.D.-M., K.R., J.J.M., J.P., D.M.M., J.G.); Intermountain Medical Center, Murray, UT (R.A.); Thomas Jefferson University, Philadelphia, PA (P.J.M.); Louisiana State University Health Science Center, Shreveport, LA (K.M.); McGill University, Montreal, Canada (R.S.); and Aurora Healthcare, Milwaukee, Wisconsin (V.T.)
| | - Kalgi Modi
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (L.A.B.); University of Pittsburgh, PA (A.D.-M., K.R., J.J.M., J.P., D.M.M., J.G.); Intermountain Medical Center, Murray, UT (R.A.); Thomas Jefferson University, Philadelphia, PA (P.J.M.); Louisiana State University Health Science Center, Shreveport, LA (K.M.); McGill University, Montreal, Canada (R.S.); and Aurora Healthcare, Milwaukee, Wisconsin (V.T.)
| | - Richard Sheppard
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (L.A.B.); University of Pittsburgh, PA (A.D.-M., K.R., J.J.M., J.P., D.M.M., J.G.); Intermountain Medical Center, Murray, UT (R.A.); Thomas Jefferson University, Philadelphia, PA (P.J.M.); Louisiana State University Health Science Center, Shreveport, LA (K.M.); McGill University, Montreal, Canada (R.S.); and Aurora Healthcare, Milwaukee, Wisconsin (V.T.)
| | - Vinay Thohan
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (L.A.B.); University of Pittsburgh, PA (A.D.-M., K.R., J.J.M., J.P., D.M.M., J.G.); Intermountain Medical Center, Murray, UT (R.A.); Thomas Jefferson University, Philadelphia, PA (P.J.M.); Louisiana State University Health Science Center, Shreveport, LA (K.M.); McGill University, Montreal, Canada (R.S.); and Aurora Healthcare, Milwaukee, Wisconsin (V.T.)
| | - Jessica Pisarcik
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (L.A.B.); University of Pittsburgh, PA (A.D.-M., K.R., J.J.M., J.P., D.M.M., J.G.); Intermountain Medical Center, Murray, UT (R.A.); Thomas Jefferson University, Philadelphia, PA (P.J.M.); Louisiana State University Health Science Center, Shreveport, LA (K.M.); McGill University, Montreal, Canada (R.S.); and Aurora Healthcare, Milwaukee, Wisconsin (V.T.)
| | - Dennis M. McNamara
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (L.A.B.); University of Pittsburgh, PA (A.D.-M., K.R., J.J.M., J.P., D.M.M., J.G.); Intermountain Medical Center, Murray, UT (R.A.); Thomas Jefferson University, Philadelphia, PA (P.J.M.); Louisiana State University Health Science Center, Shreveport, LA (K.M.); McGill University, Montreal, Canada (R.S.); and Aurora Healthcare, Milwaukee, Wisconsin (V.T.)
| | - John Gorcsan
- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (L.A.B.); University of Pittsburgh, PA (A.D.-M., K.R., J.J.M., J.P., D.M.M., J.G.); Intermountain Medical Center, Murray, UT (R.A.); Thomas Jefferson University, Philadelphia, PA (P.J.M.); Louisiana State University Health Science Center, Shreveport, LA (K.M.); McGill University, Montreal, Canada (R.S.); and Aurora Healthcare, Milwaukee, Wisconsin (V.T.)
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17
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Abstract
We experienced a case with the left atrium almost completely filled with a thrombus after orthotopic heart transplantation while the patient was supported on extracorporeal membrane oxygenation for primary graft failure. The patient had recurrent thrombosis even after successful surgical thrombectomy and appropriate anticoagulation. The cardiac thrombosis resolved only after starting plasmapheresis.
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Affiliation(s)
- Daizo Tanaka
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Harrison T Pitcher
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Paul J Mather
- Division of Cardiology, Department of Medicine, Thomas Jefferson University, 925 Chestnut, Philadelphia, Pennsylvania
| | - John W C Entwistle
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
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18
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Cavalcante JL, Marek J, Sheppard R, Starling RC, Mather PJ, Alexis JD, Narula J, McNamara DM, Gorcsan J. Diastolic function improvement is associated with favourable outcomes in patients with acute non-ischaemic cardiomyopathy: insights from the multicentre IMAC-2 trial. Eur Heart J Cardiovasc Imaging 2015; 17:1027-35. [PMID: 26628616 DOI: 10.1093/ehjci/jev311] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/28/2015] [Indexed: 11/13/2022] Open
Abstract
AIMS Patients with recent onset non-ischaemic cardiomyopathy have a variable clinical course with respect to recovery of left ventricular ejection fraction (LVEF). The aim of this study was to understand whether temporal changes in diastolic function (DF) are associated with clinical outcomes independent of LVEF recovery. METHODS AND RESULTS The Intervention in Myocarditis and Acute Cardiomyopathy (IMAC)-2 study was a prospective, multicentre trial investigating myocardial recovery in subjects with symptoms onset of <6 months and LVEF ≤40% of non-ischaemic dilated cardiomyopathy related to idiopathic cardiomyopathy or myocarditis. LVEF and DF were measured at presentation and at 6-month follow-up. Of 147 patients (mean age 46 ± 14 years, 40% female), baseline LVEF was 23 ± 8%. At 6 months, LVEF improved to 41 ± 12%, with 71% increasing by at least 10% ejection fraction units. DF improved in 58%, was unchanged in 28%, and worsened in 14%. Over a mean follow-up of 1.8 ± 1.2 years, there were 18 events: 11 heart failure (HF) hospitalizations, 3 deaths, and 4 heart transplants. LVEF (HR = 0.94, 95% CI 0.91-0.98, P = 0.002) and DF improvements at 6 months (HR = 0.32, 95% CI 0.11-0.92, P = 0.03) were independently associated with lower likelihood for the combined end point of death, transplantation, and HF hospitalization. Diastolic functional improvement at 6-month follow-up was as prognostically important as LVEF recovery for these patients, and provided incremental prognostic value to the risk stratification (X(2) increased from 12.6 to 18, P = 0.02). CONCLUSION In patients with recent onset non-ischaemic cardiomyopathy, DF recovery was associated with favourable outcomes independent of LVEF improvement, adding incremental prognostic value to these patients.
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Affiliation(s)
- João L Cavalcante
- Heart & Vascular Institute-UPMC, UPMC/University of Pittsburgh, 200 Lothrop Street, Scaife Hall, S-558, Pittsburgh, PA, USA
| | - Josef Marek
- Heart & Vascular Institute-UPMC, UPMC/University of Pittsburgh, 200 Lothrop Street, Scaife Hall, S-558, Pittsburgh, PA, USA
| | | | | | - Paul J Mather
- Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | - Dennis M McNamara
- Heart & Vascular Institute-UPMC, UPMC/University of Pittsburgh, 200 Lothrop Street, Scaife Hall, S-558, Pittsburgh, PA, USA
| | - John Gorcsan
- Heart & Vascular Institute-UPMC, UPMC/University of Pittsburgh, 200 Lothrop Street, Scaife Hall, S-558, Pittsburgh, PA, USA
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19
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Sharma S, Mather PJ, Efird JT, Kahn D, Shiue KY, Cheema M, Malloy R, Quan SF. Obstructive Sleep Apnea in Obese Hospitalized Patients: A Single Center Experience. J Clin Sleep Med 2015; 11:717-23. [PMID: 25766715 DOI: 10.5664/jcsm.4842] [Citation(s) in RCA: 27] [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: 10/01/2014] [Accepted: 02/03/2015] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is an important health problem associated with significant morbidity and mortality. This condition often is underrecognized in hospitalized patients. The aim of this study was to conduct a clinical pathway evaluation (CPE) among obese patients admitted to a tertiary care hospital. We also assessed oxygen desaturation index (ODI, measured by overnight pulse oximetry) as a potential low-cost screening tool for identifying OSA. METHODS This was a prospective study of 754 patients admitted to an academic medical center between February 2013 and February 2014. Consecutive obese patients (body mass index ≥ 30) admitted to the hospital (medical services) were screened and evaluated for OSA with the snoring, tiredness during daytime, observed apnea, high blood pressure (STOP) questionnaire. The admitting team was advised to perform follow-up evaluation, including polysomnography, if the test was positive. RESULTS A total of 636 patients were classified as high risk and 118 as low risk for OSA. Within 4 w of discharge, 149 patients underwent polysomnography, and of these, 87% (129) were shown to have OSA. An optimal screening cutoff point for OSA (apnea-hypopnea index ≥ 10/h) was determined to be ODI ≥ 10/h [Matthews correlation coefficient = 0.36, 95% confidence interval = 0.24-0.47]. Significantly more hospitalized patients were identified and underwent polysomnography compared with the year prior to introduction of the CPE. CONCLUSIONS Our results indicate that the CPE increased the identification of OSA in this population. Furthermore, ODI derived from overnight pulse oximetry may be a cost-effective strategy to screen for OSA in hospitalized patients.
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Affiliation(s)
- Sunil Sharma
- Pulmonary and Critical Care Medicine, Jefferson Sleep Disorders Center, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA
| | - Paul J Mather
- Advanced Heart Failure and Cardiac Transplant Center, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA
| | - Jimmy T Efird
- East Carolina Heart Institute, Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina University, Greenville, NC.,Center for Health Disparities, Brody School of Medicine, East Carolina University, Greenville, NC
| | - Daron Kahn
- Pulmonary and Critical Care Medicine, Jefferson Sleep Disorders Center, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA
| | - Kristin Y Shiue
- East Carolina Heart Institute, Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina University, Greenville, NC.,Center for Health Disparities, Brody School of Medicine, East Carolina University, Greenville, NC
| | - Mohammed Cheema
- Pulmonary and Critical Care Medicine, Jefferson Sleep Disorders Center, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA
| | - Raymond Malloy
- Pulmonary and Critical Care Medicine, Jefferson Sleep Disorders Center, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA
| | - Stuart F Quan
- Division of Sleep Medicine, Harvard Medical School, Boston, MA.,Arizona Respiratory Center, University of Arizona College of Medicine, Tucson, AZ
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20
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Abstract
Heart failure is a common syndrome caused by different abnormalities of the cardiovascular system that result in impairment of the ventricles in filling or ejecting blood. It is one of the most common causes of hospitalization in the United States, with a very high cost to the health care system. This article focuses on the causes of left ventricle dysfunction and the presentation and management of heart failure, both acute and chronic.
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Affiliation(s)
- Behnam Bozorgnia
- Advanced Heart Failure and Mechanical Circulatory Support, Einstein Medical Center, Moss Building, 3rd Floor, 5501 Old York Road, Philadelphia, PA 19141, USA
| | - Paul J Mather
- Advanced Heart Failure and Cardiac Transplant Center, The Jefferson Heart Institute, Jefferson Medical College of Thomas Jefferson University, 925 Chestnut Street, Suite 323A, Philadelphia, PA 19107, USA.
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21
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Blauwet L, McNamara D, Delgado-Montero A, Ryo K, Marek JJ, Alharethi R, Mather PJ, Modi K, Sheppard R, Thohan V, Pisarcik J, Gorcsan J. RIGHT VENTRICULAR SIZE AND FUNCTION AT PRESENTATION IN PERIPARTUM CARDIOMYOPATHY ARE ASSOCIATED WITH SUBSEQUENT LEFT VENTRICULAR RECOVERY. J Am Coll Cardiol 2015. [DOI: 10.1016/s0735-1097(15)60973-1] [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: 11/28/2022]
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22
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Abstract
Despite the advances in medical management of congenital and acquired cardiac disease, heart transplant remains the only curative option for certain patients. Transplant physicians aim to maintain a fine balance between too much and too little immunosuppression, so as to prevent complications such as infections, malignant growths, and toxic effects of drugs on one hand and acute or chronic rejection of the graft on the other hand. The ImmuKnow assay (by Cylex, recently acquired by Viracor-IBT Laboratories, Inc) was first introduced in 2002 by the Food and Drug Administration for detecting cell-mediated global immunity, thus providing an additional tool to help identify patients at risk for infection and rejection. All studies done to date are reviewed to examine the use of ImmuKnow in heart transplant recipients, both adults and children. Advantages and disadvantages are described, as well as areas in need of further investigation and improvement.
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Affiliation(s)
| | - Paul J Mather
- Jefferson Medical College, Thomas Jefferson University
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23
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Chandra A, Pradhan R, Kim FY, Frisch DR, Bogar LJ, Bonita R, Cavarocchi NC, Greenspon AJ, Hirose H, Pitcher HT, Rubin S, Mather PJ. Recurrent orthostatic syncope due to left atrial and left ventricular collapse after a continuous-flow left ventricular assist device implantation. J Heart Lung Transplant 2013; 32:129-33. [PMID: 23260713 DOI: 10.1016/j.healun.2012.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 09/16/2012] [Accepted: 10/17/2012] [Indexed: 01/26/2023] Open
Abstract
Left ventricular assist devices (LVADs) have become an established treatment for patients with advanced heart failure as a bridge to transplantation or for permanent support as an alternative to heart transplantation. Continuous-flow LVADs have been shown to improve outcomes, including survival, and reduce device failure compared with pulsatile devices. Although LVADs have been shown to be a good option for patients with end-stage heart failure, unanticipated complications may occur. We describe dynamic left atrial and left ventricular chamber collapse related to postural changes in a patient with a recent continuous-flow LVAD implantation.
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Affiliation(s)
- Avinash Chandra
- Department of Medicine, Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA
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24
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McNamara DM, Starling RC, Cooper LT, Boehmer JP, Mather PJ, Janosko KM, Gorcsan J, Kip KE, Dec GW. Reply. J Am Coll Cardiol 2012. [DOI: 10.1016/j.jacc.2011.10.889] [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: 11/30/2022]
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25
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Cooper LT, Mather PJ, Alexis JD, Pauly DF, Torre-Amione G, Wittstein IS, Dec GW, Zucker M, Narula J, Kip K, McNamara DM. Myocardial recovery in peripartum cardiomyopathy: prospective comparison with recent onset cardiomyopathy in men and nonperipartum women. J Card Fail 2012; 18:28-33. [PMID: 22196838 PMCID: PMC3421073 DOI: 10.1016/j.cardfail.2011.09.009] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [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] [Received: 05/13/2011] [Revised: 08/18/2011] [Accepted: 09/26/2011] [Indexed: 12/24/2022]
Abstract
BACKGROUND Whether myocardial recovery occurs more frequently in peripartum cardiomyopathy (PPCM) than in recent onset cardiomyopathies in men and nonperipartum women has not been prospectively evaluated. This was examined through an analysis of outcomes in the Intervention in Myocarditis and Acute Cardiomyopathy 2 (IMAC2) registry. METHODS AND RESULTS IMAC2 enrolled 373 subjects with recent onset nonischemic dilated cardiomyopathy. Left ventricular ejection fraction (LVEF) was assessed at entry and 6 months, and subjects followed for up to 4 years. Myocardial recovery was compared between men (group 1), nonperipartum women (group 2) and subjects with PPCM (group 3). The cohort included 230 subjects in group 1, 104 in group 2, and 39 in group 3. The mean LVEF at baseline in groups 1, 2, and 3 was 0.23 ± 0.08, 0.24 ± 0.08, and 0.27 ± 0.07 (P = .04), and at 6 months was 0.39 ± 0.12, 0.42 ± 0.11, and 0.45 ± 0.14 (P = .007). Subjects in group 3 had a much greater likelihood of achieving an LVEF >0.50 at 6 months than groups 1 or 2 (19 %, 34%, and 48% respectively, P = .002). CONCLUSIONS Prospective evaluation confirms myocardial recovery is greatest in women with PPCM, poorest in men, and intermediate in nonperipartum women. On contemporary therapy, nearly half of women with PPCM normalize cardiac function by 6 months.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Kevin Kip
- University of South Florida, Tampa, Fl
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26
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McNamara DM, Starling RC, Cooper LT, Boehmer JP, Mather PJ, Janosko KM, Gorcsan J, Kip KE, Dec GW. Clinical and demographic predictors of outcomes in recent onset dilated cardiomyopathy: results of the IMAC (Intervention in Myocarditis and Acute Cardiomyopathy)-2 study. J Am Coll Cardiol 2011; 58:1112-8. [PMID: 21884947 DOI: 10.1016/j.jacc.2011.05.033] [Citation(s) in RCA: 213] [Impact Index Per Article: 16.4] [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] [Received: 12/02/2010] [Revised: 04/12/2011] [Accepted: 05/10/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We sought to determine clinical and demographic predictors of recovery of left ventricular function for subjects with recent onset cardiomyopathy (ROCM). BACKGROUND Although ROCM is a frequent reason for consultation and transplantation referral, its prognosis and natural history on contemporary therapy are unknown. METHODS In the multicenter IMAC (Intervention in Myocarditis and Acute Cardiomyopathy)-2 study, subjects with a left ventricular ejection fraction (LVEF) of ≤0.40, fewer than 6 months of symptom duration, and an evaluation consistent with idiopathic dilated cardiomyopathy or myocarditis were enrolled. LVEF was reassessed at 6 months, and subjects were followed up for 4 years. LVEF and event-free survival were compared by race, sex, and clinical phenotype. RESULTS The cohort of 373 persons was 38% female and 21% black, with a mean age of 45 ± 14 years. At entry, 91% were receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and 82% were receiving beta-blockers, which increased to 92% and 94% at 6 months. LVEF was 0.24 ± 0.08 at entry and 0.40 ± 0.12 at 6 months (mean increase: 17 ± 13 ejection fraction units). Transplant-free survival at 1, 2, and 4 years was 94%, 92%, and 88%, respectively; survival free of heart failure hospitalization was 88%, 82%, and 78%, respectively. In analyses adjusted for sex, baseline LVEF, and blood pressure, LVEF at 6 months was significantly lower in blacks than in nonblacks (p = 0.02). Left ventricular end-diastolic diameter at presentation was the strongest predictor of LVEF at 6 months (p < 0.0001). CONCLUSIONS Outcomes in ROCM are favorable but differ by race. Left ventricular end-diastolic diameter by transthoracic echo at presentation was most predictive of subsequent myocardial recovery. (Genetic Modulation of Left Ventricular Recovery in Recent Onset Cardiomyopathy; NCT00575211).
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Affiliation(s)
- Dennis M McNamara
- Cardiovascular Institute, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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27
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Yamane K, Hirose H, Mather PJ, Silvestry SC. Mycotic pseudoaneurysm of the ascending aorta after heart transplantation: case report. Transplant Proc 2011; 43:2055-8. [PMID: 21693324 DOI: 10.1016/j.transproceed.2010.12.056] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 12/14/2010] [Indexed: 10/18/2022]
Abstract
Mycotic pseudoaneurysm of the ascending aorta is a rare but potentially life-threatening complication after orthotopic heart transplantation. We present a case of a 53-year-old man who developed a mycotic pseudoaneurysm of the ascending aorta after orthotopic heart transplantation. The pseudoaneurysm was surgically resected and the ascending aorta was replaced with allograft. The Gram stain and multiple cultures of the pseudoaneurysm wall revealed that the causative microorganism was coagulase-negative Staphylococcus. To the best of our knowledge, this is the first case report that describes mycotic pseudoaneurysm owing to coagulase-negative Staphylococcus infection after heart transplantation. Although S aureus and Pseudomonas aeruginosa are common pathogens in previously published literatures describing mycotic pseudoaneurysms in heart transplant recipients, coagulase-negative Staphylococcus is aslo an important and virulent pathogen that can cause mycotic aortic pseudoaneurysm in immunosuppressed patients. Once diagnosed, aggressive surgical treatment with prudent operative strategy, appropriate postoperative antibiotic therapy and close follow-up by radiographic study are mandatory in managing patients with this potentially fatal condition.
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Affiliation(s)
- K Yamane
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
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Brinks H, Rohde D, Voelkers M, Qiu G, Pleger ST, Herzog N, Rabinowitz J, Ruhparwar A, Silvestry S, Lerchenmüller C, Mather PJ, Eckhart AD, Katus HA, Carrel T, Koch WJ, Most P. S100A1 genetically targeted therapy reverses dysfunction of human failing cardiomyocytes. J Am Coll Cardiol 2011; 58:966-73. [PMID: 21851887 PMCID: PMC3919460 DOI: 10.1016/j.jacc.2011.03.054] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [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: 12/15/2010] [Revised: 02/07/2011] [Accepted: 03/10/2011] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study investigated the hypothesis whether S100A1 gene therapy can improve pathological key features in human failing ventricular cardiomyocytes (HFCMs). BACKGROUND Depletion of the Ca²⁺-sensor protein S100A1 drives deterioration of cardiac performance toward heart failure (HF) in experimental animal models. Targeted repair of this molecular defect by cardiac-specific S100A1 gene therapy rescued cardiac performance, raising the immanent question of its effects in human failing myocardium. METHODS Enzymatically isolated HFCMs from hearts with severe systolic HF were subjected to S100A1 and control adenoviral gene transfer and contractile performance, calcium handling, signaling, and energy homeostasis were analyzed by video-edge-detection, FURA2-based epifluorescent microscopy, phosphorylation site-specific antibodies, and mitochondrial assays, respectively. RESULTS Genetically targeted therapy employing the human S100A1 cDNA normalized decreased S100A1 protein levels in HFCMs, reversed both contractile dysfunction and negative force-frequency relationship, and improved contractile reserve under beta-adrenergic receptor (β-AR) stimulation independent of cAMP-dependent (PKA) and calmodulin-dependent (CaMKII) kinase activity. S100A1 reversed underlying Ca²⁺ handling abnormalities basally and under β-AR stimulation shown by improved SR Ca²⁺ handling, intracellular Ca²⁺ transients, diastolic Ca²⁺ overload, and diminished susceptibility to arrhythmogenic SR Ca²⁺ leak, respectively. Moreover, S100A1 ameliorated compromised mitochondrial function and restored the phosphocreatine/adenosine-triphosphate ratio. CONCLUSIONS Our results demonstrate for the first time the therapeutic efficacy of genetically reconstituted S100A1 protein levels in HFCMs by reversing pathophysiological features that characterize human failing myocardium. Our findings close a gap in our understanding of S100A1's effects in human cardiomyocytes and strengthen the rationale for future molecular-guided therapy of human HF.
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Affiliation(s)
- Henriette Brinks
- Department of Cardiac and Vascular Surgery, University Hospital Berne, Bern, Switzerland
- George Zallie and Family Laboratory for Cardiovascular Gene Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - David Rohde
- Institute for Molecular and Translational Cardiology, Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Mirko Voelkers
- Institute for Molecular and Translational Cardiology, Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Gang Qiu
- Center for Translational Medicine, Laboratory for Cardiac Stem Cell & Gene Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Sven T. Pleger
- Institute for Molecular and Translational Cardiology, Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Nicole Herzog
- Institute for Molecular and Translational Cardiology, Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Joseph Rabinowitz
- George Zallie and Family Laboratory for Cardiovascular Gene Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Arjang Ruhparwar
- Division of Cardiac Surgery, Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - Scott Silvestry
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Carolin Lerchenmüller
- Center for Translational Medicine, Laboratory for Cardiac Stem Cell & Gene Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania
- Institute for Molecular and Translational Cardiology, Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Paul J. Mather
- Advanced Heart Failure and Cardiac Transplant Center, Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Andrea D. Eckhart
- Eugene Feiner Laboratory for Vascular Biology and Thrombosis, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Hugo A. Katus
- Institute for Molecular and Translational Cardiology, Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Thierry Carrel
- Department of Cardiac and Vascular Surgery, University Hospital Berne, Bern, Switzerland
| | - Walter J. Koch
- George Zallie and Family Laboratory for Cardiovascular Gene Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Patrick Most
- Center for Translational Medicine, Laboratory for Cardiac Stem Cell & Gene Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania
- Institute for Molecular and Translational Cardiology, Department of Cardiology, University of Heidelberg, Heidelberg, Germany
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Mather PJ, Stewart H, Farber JL. Endoplasmic Reticulum Stress Is a Mechanism of Self-Progression in Congestive Heart Failure. J Card Fail 2011. [DOI: 10.1016/j.cardfail.2011.06.069] [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: 10/17/2022]
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Ho RT, Ortman M, Mather PJ, Rubin S. Inappropriate sinus tachycardia in a transplanted heart—Further insights into pathogenesis. Heart Rhythm 2011; 8:781-3. [DOI: 10.1016/j.hrthm.2010.12.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Accepted: 12/17/2010] [Indexed: 10/18/2022]
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Abstract
Cardiac dysfunction is a well-recognized complication of severe sepsis and septic shock. Cardiac dysfunction in sepsis is characterized by ventricular dilatation, reduction in ejection fraction and reduced contractility. Initially, cardiac dysfunction was considered to occur only during the "hypodynamic" phase of shock. But we now know that it occurs very early in sepsis even during the "hyperdynamic" phase of septic shock. Circulating blood-borne factors were suspected to be involved in the evolution of sepsis induced cardiomyopathy, but it is not until recently that the cellular and molecular events are being targeted by researchers in a quest to understand this enigmatic process. Septic cardiomyopathy has been the subject of investigation for nearly half a century now and yet controversies exist in understanding it's pathophysiology. Here, we discuss our understanding of the pathogenesis of septic cardiomyopathy and the complex roles played by nitric oxide, mitochondrial dysfunction, complements and cytokines.
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Affiliation(s)
- Anthony Flynn
- Cardiology, St. Louis University Hospital, 3635 Vista Ave. 13th Floor, St. Louis, MO 63110, USA
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32
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Bonita RE, Raake PW, Otis NJ, Chuprun JK, Spivack T, Dasgupta A, Whellan DJ, Mather PJ, Koch WJ. Dynamic changes in lymphocyte GRK2 levels in cardiac transplant patients: a biomarker for left ventricular function. Clin Transl Sci 2010; 3:14-8. [PMID: 20443948 DOI: 10.1111/j.1752-8062.2010.00176.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
G protein-coupled receptor kinase 2 (GRK2), which is upregulated in the failing human myocardium, appears to have a role in heart failure (HF) pathogenesis. In peripheral lymphocytes, GRK2 expression has been shown to reflect myocardial levels. This study represents an attempt to define the role for GRK2 as a potential biomarker of left ventricular function in HF patients. We obtained blood from 24 HF patients before and after heart transplantation and followed them for up to 1 year, also recording hemodynamic data and histological results from endomyocardial biopsies. We determined blood GRK2 protein by Western blotting and enzyme-linked immunosorbent assay. GRK2 levels were obtained before transplant and at first posttransplant biopsy. GRK2 levels significantly declined after transplant and remained low over the course of the study period. After transplantation, we found that blood GRK2 significantly dropped and remained low consistent with improved cardiac function in the transplanted heart. Blood GRK2 has potential as a biomarker for myocardial function in end-stage HF.
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Affiliation(s)
- Raphael E Bonita
- Department of Medicine, Division of Cardiology, Thomas Jefferson University, Philadelphia, PA, USA
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33
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Bonita RE, Raake PW, Otis NJ, Chuprun KJ, Dasgupta A, Koch WJ, Mather PJ. G-Protein Coupled Receptor Kinase Expression in Lymphocytes – A Novel Biomarker of Left Ventricular Systolic Function in Heart Failure Patients. J Card Fail 2009. [DOI: 10.1016/j.cardfail.2009.06.407] [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: 11/25/2022]
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34
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Van Why CJ, Pierson N, Flanagan C, Canny A, Bilkins J, Cozzi S, Connolly M, Shore E, Rubin S, Silvestry S, Whellan D, Bogar L, Mather PJ. Barriers to Heart Transplantation: One Urban Center's Findings. J Card Fail 2009. [DOI: 10.1016/j.cardfail.2009.06.277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
In a national heart failure registry, hyponatremia (serum sodium < 130 mEq/L) was initially reported in 5% of patients and considered a risk factor for increased morbidity and mortality. In a chronic heart failure study, serum sodium level on admission predicted an increased length of stay for cardiovascular causes and increased mortality within 60 days of discharge. Hyponatremia in patients with congestive heart failure (CHF) is associated with a higher mortality rate. Also, by monitoring and increasing serum sodium levels during hospitalization for CHF, patient outcomes may improve. This review describes the pathophysiology of hyponatremia in relation to CHF, including the mechanism of action of vasopressin receptors in the kidney, and assesses the preclinical and clinical trials of vasopressin receptor antagonists--agents recently developed to treat hyponatremia. In hospitalized patients with CHF, hyponatremia plays a major role in poor outcomes. Vasopressin receptor antagonists have been shown to be safe and effective in clinical trials in patients with hyponatremia.
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Affiliation(s)
- Siva Kumar
- Advanced Heart Failure and Cardiac Transplant Center, Jefferson Heart Institute, Jefferson Medical College, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107, USA.
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37
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Abstract
Over the past 2 decades, investigators have learned more about the pathophysiologic changes that occur in systolic and diastolic dysfunction. Ironically, in some cases, the biologic pathways that have protected the heart during acute dysfunction are the same pathways that cause progressive deleterious effects with chronic activation. In particular, it is the activation of the neurohormonal system that has a significant impact on disease progression. As a result, the neurohormonal system has provided a key target for pharmacologic therapy in patients with heart failure secondary to systolic dysfunction. These targets include the renin-angiotensin-aldosterone system as well as the sympathetic nervous system. Neurohormonal manipulation, however, is often ineffective in the pharmacologic therapy of patients with endstage heart failure, therefore other treatment strategies - including the use of inotropic agents to improve pump function and diuretics to control fluid balance are needed.
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Affiliation(s)
- Eman Hamad
- Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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38
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Abstract
Heart failure is a growing epidemic with an estimated 5 million Americans suffering from this condition. Several clinical trials have demonstrated a high correlation between congestive heart failure (CHF) and cognitive impairment. The severity of cognitive impairment correlates positively with the degree of CHF. The underlying mechanism for cognitive impairment remains unclear but appears to be related to cerebral hypoperfusion and impaired cerebral reactivity with selective impairment of verbal memory and attention domains. Furthermore, cognitive dysfunction represents one aspect of frailty, a novel concept that encompasses a range of clinical conditions that results in functional impairment in patients with heart failure. In addition, frailty independently predicts mortality in CHF patients. Cognitive impairment is a common and predictable effect of CHF that contributes with social and behavioral problems to decreased compliance to prescribed therapy and increased hospital readmissions. A multidisciplinary approach is necessary to deal with the complexity of this clinical syndrome.
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Affiliation(s)
- Michael B Cohen
- Jefferson Medical College of Thomas Jefferson Heart University, Philadelphia, PA 19107, USA
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Abstract
Cardiomyopathy represents a diverse and heterogenous group of disorders affecting the myocardium and ultimately resulting in cardiac dysfunction. The prevalence of heart failure is high (5 million symptomatic patients in the United States) and increasing. Cardiomyopathy is the leading cause of hospitalization in patients older than 65 years of age, resulting in enormous healthcare expenditure and lost productivity. Ischemic cardiomyopathy accounts for about half of these patients, but in several large clinical trials the prevalence of potentially reversible nonischemic cardiomyopathy is also significant, ranging from 20% to 50%. There is epidemiological evidence that the prognosis of these reversible nonischemic cardiomyopathies is better than ischemic or other nonreversible cardiomyopathies. Early and precise diagnosis of the etiology of heart failure is important for determining prognosis and effective treatments.
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Abstract
Heart Failure is the only cardiovascular disease diagnosis increasing in prevalence in the United States. Currently there are more than 5 million people diagnosed with heart failure in the United States and that population is increasing exponentially. Clinical trials in advanced pharmacological therapies have shown a significant value in reducing the morbidity and mortality of the disease process. Nevertheless, many patients who are optimally treated with drug therapy continue to progress from asymptomatic left ventricular dysfunction to symptomatic and then end-stage heart failure. Beyond drug therapy, devices have begun to make a significant impact on symptoms and clinical outcomes in patients, particularly those with more advanced forms of heart failure. New technologies being investigated include destination and bridge LV assist devices. Due to the invasive nature of these devices a new generation of "less invasive" percutaneous devices are now being studied. These new generation devices offer the promise of improved LV function and an enhanced neurohormonal profile for the failing ventricle, thus improving the quality of life in the ever-burgeoning heart failure population.
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Affiliation(s)
- Paul J Mather
- Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA, USA.
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41
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Saltzman HE, Sharma K, Mather PJ, Rubin S, Adams S, Whellan DJ. Renal dysfunction in heart failure patients: what is the evidence? Heart Fail Rev 2007; 12:37-47. [PMID: 17393304 DOI: 10.1007/s10741-007-9006-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2006] [Accepted: 02/13/2007] [Indexed: 01/13/2023]
Abstract
Congestive heart failure (CHF) is an increasingly common medical condition and the fastest growing cardiovascular diagnosis in North America. Over one-third of patients with heart failure also have renal insufficiency. It has been shown that renal insufficiency confers worsened outcomes to patients with heart failure. However, a majority of the larger and therapy-defining heart failure medication and device trials exclude patients with advanced renal dysfunction. These studies also infrequently perform subgroup analyses based on the degree of renal dysfunction. The lack of information on heart failure patients who have renal insufficiency likely contributes to their being prescribed mortality and morbidity reducing medications and receiving diagnostic and therapeutic procedures at lower rates than heart failure patients with normal renal function. Inclusion of patients with renal insufficiency in heart failure studies and published guidelines for medication, device, and interventional therapies would likely improve patient outcomes.
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Affiliation(s)
- Heath E Saltzman
- Department of Medicine, Jefferson Medical College, Jefferson Heart Institute, Thomas Jefferson University, 925 Chestnut Street, #135, Mezzanine Level, Philadelphia, PA 19107, USA
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42
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Abstract
Heart failure is the only cardiovascular disease diagnosis increasing in prevalence in the United States. A number of drugs have been shown to reduce morbidity and mortality in patients with chronic heart failure. Despite these advances, the frequency of hospitalization for heart failure has continued to increase, and clinical trial data are lacking in demonstrable benefit of drug therapy for patients hospitalized with acute, decompensated heart failure. A number of percutaneous devices have been developed and are in various stages of investigation and use to improve symptoms and clinical outcomes in patients hospitalized with heart failure. These include "add-on" devices, such as continuous aortic flow augmentation and ultrafiltration devices, and "rescue" devices to be used in patients who are rapidly deteriorating despite medical therapy. In addition to the intra-aortic balloon pump, newer approaches include percutaneous ventricular assist devices that are available for short-term use to stabilize patients until recovery can occur or as "bridges" to longer-term assist or cardiac transplantation. In the coming years, expanded clinical investigation is likely to explore the potential for devices to normalize underlying cardiac function and thereby improve long-term clinical outcomes.
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Affiliation(s)
- Paul J Mather
- Jefferson Heart Institute, 925 Chestnut Street, Mezzanine, Philadelphia, PA 19107, USA.
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Leech SH, Rubin S, Eisen HJ, Mather PJ, Goldman BI, McClurken JB, Furukawa S. Cardiac transplantation across a positive prospective lymphocyte cross-match in sensitized recipients. Clin Transplant 2004; 17 Suppl 9:17-26. [PMID: 12795663 DOI: 10.1034/j.1399-0012.17.s9.3.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [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: 11/23/2022]
Abstract
BACKGROUND Although there is an increasing body of evidence for a deleterious effect of mismatched donor HLA antigens on the outcome of human cardiac transplantation, the role of anti-HLA lymphocytotoxic antibodies remains controversial. Thus, their appearance after cardiac transplantation has been associated with poor outcome by some groups; whereas others have reported them to be of no clinical significance. Furthermore, their presence prior to cardiac transplantation has also been the subject of similarly conflicting reports. The deleterious effect of such pre-existing antibodies has been predicted by a positive lymphocyte cross-match (LCM), which, for most patients awaiting renal transplantation and in many requiring a cardiac allograft, leads to cancellation of the operation. The reason for undertaking the current study was to test the hypothesis that the constraints which a positive LCM result impose in preventing renal transplantation may not apply to orthotopic heart transplantation (OHT). PATIENTS AND METHODS Four sensitized patients underwent OHT across a positive prospective LCM. Three were females, and one of those females also underwent cadaveric renal transplantation at the time of OHT. All four patients received aggressive early post-transplant immunosuppressive therapy, which included plasmapheresis, intravenous immunoglobulin (IVIg), antiproliferative agents (cyclophosphamide, basiliximab) and cytokine down-regulators (calcineurin inhibitors, muromonab-CD3) and anticell antibodies (OKT3, ATG). They also received standard immunosuppressive therapy which included corticosteroids. Complement-dependent cytotoxicity (CDC) was used for the identification of anti-HLA lymphocytotoxic antibodies. Reactivity of the latter against more than 10% of a panel of well-characterized T cells was considered sensitization, and required LCM to be performed prospectively, which test was also performed using the CDC technique. RESULTS Three of the patients exhibited evidence suggestive of acute or hyperacute rejection in endomyocardial biopsy specimens by postoperative day (POD) 7. Two of the three patients with rejection also exhibited haemodynamic instability (elevated filling pressures and reduced cardiac index) on POD 1, which improved with inotropic support. One patient sustained a cardiac arrest on POD 7, and was successfully resuscitated without sequelae. All patients are now doing well, postoperatively (follow-up: 17-57 months) post-transplant. Two patients have normal left ventricular function and one patient has mild left ventricular dysfunction. Two have no further evidence of sensitization (PRA < 10%). CONCLUSIONS Although the number of patients in this study is small, the long-term successful outcome of OHT following positive prospective cross-matches suggests that such a test result, in contrast to the restraints it imposes on renal transplantation, may not be a contra-indication to transplantation of the human heart. If OHT proceeds after the LCM is reported positive, aggressive immunotherapy should not only be initiated early, but should also be targeted at humoral-vascular rejection in particular.
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Affiliation(s)
- Stephen H Leech
- Departments of Pathology and Laboratory Medicine, Temple University Hospital and School of Medicine, Philadelphia, PA, USA
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44
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Gowda SA, Gaughan JP, Mather PJ. Hemodialysis in the orthotopic heart transplantation population. J Card Fail 2003. [DOI: 10.1016/s1071-9164(03)00230-6] [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: 10/27/2022]
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45
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Mather PJ, Santamore WP, Yu X, Bove AA. The Impact of a Telemedicine System on Improving Clinical Cardiovascular Care. J Card Fail 2003. [DOI: 10.1016/s1071-9164(03)00226-4] [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] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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46
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Mather PJ, Shah R. Echocardiography, nuclear scintigraphy, and stress testing in the emergency department evaluation of acute coronary syndrome. Emerg Med Clin North Am 2001; 19:339-49. [PMID: 11373982 DOI: 10.1016/s0733-8627(05)70187-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [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]
Abstract
There are between 3 and 5 million visits to EDs each year for complaints of chest pain. Of these, about one half of the patients have a noncardiac cause for their chest pain. Of the remainder, about 30% to 50% have significant coronary disease. It is quite clear that patients who are at high risk for a coronary event should be admitted to the hospital. For the low-to-moderate risk patients, the decision to admit or discharge the patient from the ED is not quite so easy. The emergency physician has to decide which tests can be helpful in the decision-making process, this can be undertaken in conjunction with a consultative cardiologist. It can be argued that if a patient does not have a normal test result whichever that evaluatory test is), then the patient should be admitted for further work-up and evaluation. The easiest test to perform in the ED setting is an echocardiogram. The images can be sent by telecommunication to a qualified echocardiogram reader for interpretation. This also has a reasonable NPV, although not necessarily as good as some of the other modalities available, unless interpreted in light of cardiac enzyme test results. If the index of suspicion is still high, then a stress echocardiogram can be considered. This has an excellent NPV and can be easily performed in [table: see text] most patients. This should not be undertaken in the face of an evolving MI, and patients should be observed for at least 8 hours after their initial presentation to the ED prior to undergoing a provocative test. Nuclear scintigraphy, another modality available for cardiac risk stratification, can be a logistical nightmare. The nuclear isotopes are strictly regulated by the Nuclear Regulatory Commission. The emergency physician may inject the isotopes, provided that he or she has undergone the necessary radiation training. Also, the patient must be removed from the ED to a radioisotope-approved area for the duration of the scan. One of the most difficult questions left open after review of all these analytical modalities is the duration of time these test results remain valid; when does an individual patient need to be reevaluated as to their specific pretest probability? The answer to this question lies in the presenting clinical scenario. If the patient presents with a similar inciting trigger for his or her symptoms, and the cardiac risk profile has not changed appreciably, then the previous study (whether a provocative stress test or even a cardiac catheterization) probably can be reliably counted. If the patient's risk profile has changed or the symptoms are new or more intense, the physician is compelled to pursue this encounter as a new, acute event. This can be true even in the setting of a previous cardiac catheterization that showed nonobstructive coronary disease, because plaque rupture can be acute and unpredictable. Ultimately, optimal care calls for each institution to develop a specific approach, in conjunction with their consultative cardiologist or critical care specialist, to enhance patient care, safety, and diagnostic outcome, while maintaining cost efficiency.
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Affiliation(s)
- P J Mather
- Advanced Heart Failure and Transplantation Center, Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
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47
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Abstract
Retrospective analysis of 200 homograft valve recipients at our institution revealed two cases of fungal endocarditis. Pathogenesis appears to be related to either recipient seeding in one elderly immunocompromised patient or a previously contaminated donor valve implanted in an otherwise healthy recipient. Therefore, our experience underscores the need for both meticulous prevention of fungal infection preoperatively in the recipient and elimination of previously contaminated homograft valves from the donor pool.
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Affiliation(s)
- P A Fedalen
- Division of Cardiac and Thoracic Surgery, Temple University Health Sciences Center, Philadelphia, Pennsylvania 19140, USA
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48
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Leech SH, Mather PJ, Eisen HJ, Pina IL, Margulies KB, Bove AA, Jeevanandam V. Donor-specific HLA antibodies after transplantation are associated with deterioration in cardiac function. Clin Transplant 1996; 10:639-45. [PMID: 8996758] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Although there is increasing evidence that mismatched donor HLA antigens are associated with a lowering of survival of human cardiac allografts, the effect of antibodies that bind those antigens is less clear. The existence of lymphocytotoxic antibodies prior to cardiac transplantation has been associated with a poor outcome in the majority of reports of relevant studies, as has their appearance post-transplantation. But how such antibodies, especially those with HLA specificity, cause poor outcomes has been poorly understood. The purpose of this study was to investigate the effect of anti-HLA antibodies appearing in the circulation after human orthotopic heart transplantation. Such antibodies were identified by a standard microlymphocytotoxicity technique using panels of frozen lymphocytes from normal donors who had been tissue typed. Of 74 patients transplanted over a 12-month period, 4 (5.4%) developed alloantibodies specific for mismatched donor HLA antigens. The first patient developed antibodies to HLA-A23 and B44 together with poor ventricular function and vascular rejection requiring retransplantation within 4 months. The other patients (3) developed antibodies specific for HLA-DQ antigens and experienced variable numbers of episodes of cellular rejection with no evidence of vascular rejection on endomyocardial biopsy. Two of these three patients died (8 and 11 months post-transplant) after three and six rejection episodes, respectively. The one surviving patient had seven rejection episodes and continues to have poor ventricular function 18 months post-transplant. We conclude that alloantibodies specific for mismatched donor HLA antigens may have a deleterious effect on the outcome of the human cardiac allograft and should be monitored closely post-transplant. Furthermore, such antibodies may mediate effects on the transplanted heart which are not detectable in specimens obtained by endomyocardial biopsy.
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Affiliation(s)
- S H Leech
- Department of Pathology, Temple University Hospital, Philadelphia, Pennsylvania 19140, USA
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49
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McClurken JB, Todd BA, Mather PJ, Pina I, Bove AA, Addonizio VP, Jeevanandam V. Recipient-donor atrial synchronization benefits acute hemodynamics after orthotopic heart transplantation. J Heart Lung Transplant 1996; 15:368-70. [PMID: 8732595] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- J B McClurken
- Department of Surgery, Temple University Health Science Center, Philadelphia, Pa 19140, USA
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50
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Leech SH, Mather PJ, Eisen HJ, Jeevanandam V. Deterioration in cardiac function is associated with the appearance of specific HLA antibodies after transplantation. J Am Coll Cardiol 1996. [DOI: 10.1016/s0735-1097(96)80685-1] [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: 10/27/2022]
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