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Inglis SS, Asleh R, Iyer VN, Schettle SD, Spencer PJ, Villavicencio MA, Rodeheffer RJ, Kushwaha SS, Behfar A, Rosenbaum AN. Inhibition of angiogenesis in the management of refractory gastrointestinal bleeding in patients with LVAD support. Artif Organs 2024; 48:646-654. [PMID: 38131635 DOI: 10.1111/aor.14694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/09/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) in patients with continuous flow left ventricular assist devices (CF-LVADs) is often related to GI angiodysplasia (GIAD). We previously reported data on VEGF inhibition with IV bevacizumab in the treatment of LVAD-associated GIAD bleeding, and now present follow-up data on patients treated with IV bevacizumab and/or low-dose oral pazopanib. METHODS All consecutive adult patients with LVAD-associated GIB from GIAD treated with bevacizumab or pazopanib, from July 20, 2017 to June 22, 2022, were included in the analysis. Data on hospitalizations, GI endoscopic procedures, and blood transfusions were obtained from first admission for GIB up to a median of 35.7 months following treatment initiation (range 1.3-59.8 months). RESULTS Eleven patients (91% male, mean 69.5 ± 8.9 years) were included. Eight patients (73%) received IV bevacizumab, two patients (18%) received oral pazopanib, and one patient (9%) received bevacizumab followed by pazopanib therapy. We observed a significantly decreased number of annualized hospitalizations for GIB (median difference - 2.87, p = 0.002), blood transfusions (median difference - 20.9, p = 0.01), and endoscopies (median difference - 6.95, p = 0.007) in patients pre- and post-anti-angiogenic therapy (bevacizumab and/or pazopanib). Similarly, a significant improvement in these clinical outcomes was noted in the bevacizumab group with decreased annualized hospitalizations (median difference - 2.75, p = 0.014), blood transfusions (median difference - 24.5, p = 0.047), and number of endoscopies (median differences -6.88, p = 0.006). CONCLUSION Anti-angiogenic therapy with IV bevacizumab and/or low-dose oral pazopanib appears to provide benefits in patients with LVAD-associated GIB with reduced hospitalizations, blood transfusions, and need for GI endoscopic procedures.
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Affiliation(s)
- Sara S Inglis
- Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Rabea Asleh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vivek N Iyer
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarah D Schettle
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Philip J Spencer
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Sudhir S Kushwaha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Atta Behfar
- Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew N Rosenbaum
- Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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2
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Inglis SS, Rosenbaum AN, Rizzo SA, Anderson JH, Yalamuri S, Spencer PJ, Villavicencio MA, Behfar A. Novel Left Ventricular Unloading Strategies in Patients on Peripheral Venoarterial Extracorporeal Membrane Oxygenation Support. ASAIO J 2024; 70:396-403. [PMID: 38181416 DOI: 10.1097/mat.0000000000002136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024] Open
Abstract
The purpose of this study was to evaluate left ventricular (LV) unloading strategies in patients supported with peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO). A retrospective review was conducted of all consecutive patients requiring VA-ECMO support for any indication, who underwent novel LV unloading strategies with either direct left atrial venoarterial (LAVA) cannulation or pulmonary artery venoarterial (PAVA) venting, in comparison to Impella and intra-aortic balloon pump (IABP). The primary outcome was successful bridge to transplant, LV assist device, or myocardial recovery. Forty-six patients (63% male, mean age 52.8 ± 17.6 years) were included. Fourteen patients (30%) underwent novel unloading with either LAVA or PAVA, 11 patients (24%) underwent IABP placement, and 21 patients (46%) underwent Impella insertion. In the novel LV unloading cohort, 10 patients (71%) survived to hospital discharge. Four patients (29%) were weaned from ECMO and eight patients (57%) underwent cardiac transplantation. Although a trend favoring cannula-based unloading for the primary outcome was noted, the cohort was too small for statistical significance (79% LAVA/PAVA, 57% Impella, 45% IABP; p = 0.21). However, probability of survival was greater in the LAVA/PAVA cohort compared to Impella and IABP ( p < 0.05). Thus, we demonstrate the efficacy of LA and PA cannulation as an alternative LV unloading strategy for patients supported with peripheral VA-ECMO.
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Affiliation(s)
- Sara S Inglis
- From the Van Cleve Cardiac Regenerative Medicine Program, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Skylar A Rizzo
- From the Van Cleve Cardiac Regenerative Medicine Program, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Medical Scientist Training Program, Mayo Clinic Alix School of Medicine, Rochester, Minnesota
| | - Jason H Anderson
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Suraj Yalamuri
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Philip J Spencer
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Atta Behfar
- From the Van Cleve Cardiac Regenerative Medicine Program, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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3
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Inglis SS, Rosenbaum AN. Professional Employment With Left Ventricular Assist Device Support: Does Working With an LVAD Allow It to Work Too? ASAIO J 2024; 70:356-357. [PMID: 38457524 DOI: 10.1097/mat.0000000000002187] [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] [Subscribe] [Scholar Register] [Indexed: 03/10/2024] Open
Affiliation(s)
- Sara S Inglis
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Sykora D, Rosenbaum AN, Churchill RA, Kim BM, Elwazir MY, Bois JP, Giudicessi JR, Bratcher M, Young KA, Ryan SM, Sugrue AM, Killu AM, Chareonthaitawee P, Kapa S, Deshmukh AJ, Abou Ezzeddine OF, Cooper LT, Siontis KC. Arrhythmic manifestations and outcomes of definite and probable cardiac sarcoidosis. Heart Rhythm 2024:S1547-5271(24)02326-9. [PMID: 38588996 DOI: 10.1016/j.hrthm.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The 2014 Heart Rhythm Society consensus statement defines histological (definite) and clinical (probable) diagnostic categories of cardiac sarcoidosis (CS), but few studies have compared their arrhythmic phenotypes and outcomes. OBJECTIVE The purpose of this study was to evaluate the electrophysiological/arrhythmic phenotype and outcomes of patients with definite and probable CS. METHODS We analyzed the arrhythmic/electrophysiological phenotype in a single-center North American cohort of 388 patients (median age 56 years; 39% female, n = 151) diagnosed with definite (n = 58) or probable (n = 330) CS (2000-2022). The primary composite outcome was survival to first ventricular tachycardia/fibrillation (VT/VF) event or sudden cardiac death. Key secondary outcomes were also assessed. RESULTS At index evaluation, in situ cardiac implantable electronic devices and antiarrhythmic drug use were more common in definite CS. At a median follow-up of 3.1 years, the primary outcome occurred in 22 patients with definite CS (38%) and 127 patients with probable CS (38%) (log-rank, P = .55). In multivariable analysis, only a higher ratio of the 18F-fluorodeoxyglucose maximum standardized uptake value of the myocardium to the maximum standardized uptake value of the blood pool (hazard ratio 1.09; 95% confidence interval 1.03-1.15; P = .003, per 1 unit increase) was associated with the primary outcome. During follow-up, patients with definite CS had a higher burden of device-treated VT/VF events (mean 2.86 events per patient-year vs 1.56 events per patient-year) and a higher rate of progression to heart transplant/left ventricular assist device implantation but no difference in all-cause mortality compared with patients with probable CS. CONCLUSION Patients with definite and probable CS had similarly high risks of first sustained VT/VF/sudden cardiac death and all-cause mortality, though patients with definite CS had a higher overall arrhythmia burden. Both CS diagnostic groups as defined by the 2014 Heart Rhythm Society criteria require an aggressive approach to prevent arrhythmic complications.
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Affiliation(s)
- Daniel Sykora
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - B Michelle Kim
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mohamed Y Elwazir
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - John P Bois
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - John R Giudicessi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Melanie Bratcher
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kathleen A Young
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sami M Ryan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Alan M Sugrue
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ammar M Killu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Suraj Kapa
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida
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5
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Garmany A, Inglis SS, Behfar A, Rosenbaum AN. Biventricular catheterization combined with pressure-volume loop monitoring provides insight into the dynamic effects of left ventricular assist devices ramp on right ventricular function. Catheter Cardiovasc Interv 2024; 103:799-802. [PMID: 38461378 PMCID: PMC11037112 DOI: 10.1002/ccd.30993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/12/2024] [Accepted: 02/16/2024] [Indexed: 03/11/2024]
Abstract
Ramp studies are utilized for speed optimization of continuous flow left ventricular assist devices (CF-LVADs). We here report the utility of combined left and right heart catheterization during a ramp study to ensure a comprehensive understanding of the hemodynamic implications on both ventricles. Pressure-volume loop (PV loop) monitoring uncovered compromised systolic and mildly compromised right ventricular function with increasing LVAD speeds, despite improvement in left ventricular unloading. These findings informed patient management and highlight the potential utility of PV loop monitoring as an adjunct to left and right heart catheterization during ramp studies of next-generation LVADs.
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Affiliation(s)
- Armin Garmany
- Graduate School of Biomedical Sciences, Alix School of Medicine, Medical Scientist Training Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Sara S. Inglis
- Department of Cardiovascular Medicine, Division of Circulatory Failure, Mayo Clinic, Rochester, Minnesota
- VanCleve Cardiac Regenerative Medicine Program and Fong Chao Foundation, Center for Regenerative Medicine, Mayo Clinic Rochester MN
| | - Atta Behfar
- Department of Cardiovascular Medicine, Division of Circulatory Failure, Mayo Clinic, Rochester, Minnesota
- William J von Liebig Center for Transplantation and Clinical Regeneration. Mayo Clinic, Rochester, Minnesota
- VanCleve Cardiac Regenerative Medicine Program and Fong Chao Foundation, Center for Regenerative Medicine, Mayo Clinic Rochester MN
| | - Andrew N. Rosenbaum
- Department of Cardiovascular Medicine, Division of Circulatory Failure, Mayo Clinic, Rochester, Minnesota
- VanCleve Cardiac Regenerative Medicine Program and Fong Chao Foundation, Center for Regenerative Medicine, Mayo Clinic Rochester MN
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6
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Neves R, Tseng AS, Garmany R, Fink AL, McLeod CJ, Cooper LT, MacIntyre CJ, Homb AC, Rosenbaum AN, Bois JP, Abou Ezzeddine OF, Siontis KC, Pereira NL, Ackerman MJ, Giudicessi JR. Cardiac fludeoxyglucose-18 positron emission tomography in genotype-positive arrhythmogenic cardiomyopathy. Int J Cardiol 2023; 389:131173. [PMID: 37423567 DOI: 10.1016/j.ijcard.2023.131173] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/20/2023] [Accepted: 07/06/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Myocardial inflammation contributes to the pathogenesis of arrhythmogenic cardiomyopathy (ACM), a clinically and genetically heterogenous disorder. Due to phenotypic overlap, some patients with genetic ACM may be evaluated for an underlying inflammatory cardiomyopathy. However, the cardiac fludeoxyglucose (FDG) positron emission tomography (PET) findings in ACM patients have not been elucidated. METHODS All genotype-positive patients in the Mayo Clinic ACM registry (n = 323) who received a cardiac FDG PET were included in this study. Pertinent data were extracted from the medical record. RESULTS Collectively, 12/323 (4%; 67% female) genotype-positive ACM patients received a cardiac PET FDG scan as part of their clinical evaluation (median age at scan 49 ± 13 years). Amongst these patients, pathogenic/likely pathogenic variants were detected in LMNA (n = 7), DSP (n = 3), FLNC (n = 1) and PLN (n = 1). Of note, 6/12 (50%) had abnormal myocardial FDG uptake, including diffuse (entire myocardium) uptake in 2/6 (33%), focal (1-2 segments) uptake in 2/6 (33%) and patchy (3+ segments) in 2/6 (33%). Median myocardial standardized uptake value ratio was 2.1. Interestingly, LMNA-positive patients accounted for 3 out of 6 (50%) positive studies (diffuse uptake in 2 and focal uptake in 1). CONCLUSION Abnormal myocardial FDG uptake is common in genetic ACM patients undergoing cardiac FDG PET. This study further supports the role of myocardial inflammation in ACM. Further investigation is needed to determine role of FDG PET in diagnosis and management of ACM and investigate the role of inflammation in ACM.
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Affiliation(s)
- Raquel Neves
- Department of Molecular Pharmacology & Experimental Therapeutics (Windland Smith Rice Sudden Death Genomics Laboratory), Mayo Clinic, Rochester, MN, USA
| | - Andrew S Tseng
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Ramin Garmany
- Department of Molecular Pharmacology & Experimental Therapeutics (Windland Smith Rice Sudden Death Genomics Laboratory), Mayo Clinic, Rochester, MN, USA; Medical Scientist Training Program, Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Angela L Fink
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | - Andrew C Homb
- Department of Diagnostic Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - John P Bois
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Naveen L Pereira
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael J Ackerman
- Department of Molecular Pharmacology & Experimental Therapeutics (Windland Smith Rice Sudden Death Genomics Laboratory), Mayo Clinic, Rochester, MN, USA; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA; Department of Pediatric and Adolescent Medicine (Division of Pediatric Cardiology), Mayo Clinic, Rochester, MN, USA
| | - John R Giudicessi
- Department of Molecular Pharmacology & Experimental Therapeutics (Windland Smith Rice Sudden Death Genomics Laboratory), Mayo Clinic, Rochester, MN, USA; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
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7
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Castrichini M, Agboola KM, Vyas H, Abou Ezzeddine OF, Siontis KC, Giudicessi JR, Rosenbaum AN, Pereira NL. Cardiac Sarcoidosis Mimickers: Genetic Testing in Undifferentiated Inflammatory Cardiomyopathies. Circ Genom Precis Med 2023; 16:478-479. [PMID: 37401491 DOI: 10.1161/circgen.123.004099] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Affiliation(s)
| | - Kolade M Agboola
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Hridyanshu Vyas
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | | | | | | | - Naveen L Pereira
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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8
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Inglis SS, Thomas SC, Bois MC, Rosenbaum AN. Case Series: Recurrence of Cardiac Sarcoidosis After Orthotopic Heart Transplantation. Transplant Proc 2023; 55:1688-1691. [PMID: 37407375 DOI: 10.1016/j.transproceed.2023.03.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 02/23/2023] [Accepted: 03/30/2023] [Indexed: 07/07/2023]
Abstract
Orthotopic heart transplantation for cardiac sarcoidosis (CS) is becoming increasingly common. Historically, there have been concerns regarding disease recurrence within the allograft. Although rarely reported in the literature, cases of recurrent CS tend to be observed in patients after dose reduction of immunosuppressive therapy and cessation of corticosteroids. Here, we present 2 cases of recurrent CS after orthotopic heart transplantation, confirmed on endomyocardial biopsy. Case 1 reports a 50-year-old man with a fulminant course of giant cell myocarditis who developed allograft recurrence with granulomas 5 years after transplantation despite maintenance corticosteroid therapy. Case 2 reports a 47-year-old man with CS who developed recurrence with the presence of giant cells 2 years after transplantation, with a benign clinical course. With these cases, we demonstrate the clinical overlap between CS and giant cell myocarditis and highlight the spectrum of the disease process. We also demonstrate that CS can recur despite corticosteroid maintenance therapy.
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Affiliation(s)
- Sara S Inglis
- Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
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9
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Inglis SS, Suh GA, Razonable RR, Schettle SD, Spencer PJ, Villavicencio MA, Rosenbaum AN. Infections in Patients With Left Ventricular Assist Devices: Current State and Future Perspectives. ASAIO J 2023; 69:633-641. [PMID: 37145863 DOI: 10.1097/mat.0000000000001956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
Mechanical circulatory support is increasingly being used as bridge-to-transplant and destination therapy in patients with advanced heart failure. Technologic improvements have led to increased patient survival and quality of life, but infection remains one of the leading adverse events following ventricular assist device (VAD) implantation. Infections can be classified as VAD-specific, VAD-related, and non-VAD infections. Risk of VAD-specific infections, such as driveline, pump pocket, and pump infections, remains for the duration of implantation. While adverse events are typically most common early (within 90 days of implantation), device-specific infection (primarily driveline) is a notable exception. No diminishment over time is seen, with event rates of 0.16 events per patient-year in both the early and late periods postimplantation. Management of VAD-specific infections requires aggressive treatment and chronic suppressive antimicrobial therapy is indicated when there is concern for seeding of the device. While surgical intervention/hardware removal is often necessary in prosthesis-related infections, this is not so easily accomplished with VADs. This review outlines the current state of infections in patients supported with VAD therapy and discusses future directions, including possibilities with fully implantable devices and novel approaches to treatment.
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Affiliation(s)
- Sara S Inglis
- From the Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, Minnesota
| | - Gina A Suh
- Department of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | | | - Sarah D Schettle
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Philip J Spencer
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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10
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Rosenbaum AN, Rossman TL, Reddy YN, Villavicencio MA, Stulak JM, Spencer PJ, Kushwaha SS, Behfar A. Pulsatile Pressure Delivery of Continuous-Flow Left Ventricular Assist Devices Is Markedly Reduced Relative to Heart Failure Patients. ASAIO J 2023; 69:445-450. [PMID: 36417497 DOI: 10.1097/mat.0000000000001859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Although continuous-flow left ventricular assist devices (CF-LVADs) provide an augmentation in systemic perfusion, there is a scarcity of in vivo data regarding systemic pulsatility on support. Patients supported on CF-LVAD therapy (n = 71) who underwent combined left/right catheterization ramp study were included. Aortic pulsatility was defined by the pulsatile power index (PPI), which was also calculated in a cohort of high-output heart failure (HOHF, n = 66) and standard HF cohort (n = 44). PPI was drastically lower in CF-LVAD-supported patients with median PPI of 0.006 (interquartile range [IQR], 0.002-0.012) compared with PPI in the HF population at 0.09 (IQR, 0.06-0.17) or HOHF population at 0.25 (IQR, 0.13-0.37; p < 0.0001 among groups). With speed augmentation during ramp, PPI values fell quickly in patients with higher PPI at baseline. PPI correlated poorly with left ventricular ejection fraction (LVEF) in all groups. In CF-LVAD patients, there was a stronger correlation with LV dP/dt (r = 0.41; p = 0.001) than LVEF (r = 0.21; p = 0.08; pint < 0.001). CF-LVAD support is associated with a dramatic reduction in arterial pulsatility as measured by PPI relative to HOHF and HF cohorts and decreases with speed. Further work is needed to determine the applicability to the next generation of device therapy.
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Affiliation(s)
- Andrew N Rosenbaum
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
- Van Cleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Yogesh N Reddy
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Philip J Spencer
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sudhir S Kushwaha
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | - Atta Behfar
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
- Van Cleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota
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11
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Ranganath N, Issa NS, Rosenbaum AN, Beam E, Mahmood M. Use of Novel Diagnostic Approaches to Identify Disseminated Ureaplasma urealyticum Infection Causing Hyperammonemia Syndrome After Heart-Kidney Transplant. Mayo Clin Proc 2023; 98:804-806. [PMID: 37137649 DOI: 10.1016/j.mayocp.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 05/05/2023]
Affiliation(s)
- Nischal Ranganath
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN
| | - Naim S Issa
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Andrew N Rosenbaum
- Division of Circulatory Failure, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Elena Beam
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN
| | - Maryam Mahmood
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN
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12
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Inglis SS, Villavicencio MT, Spencer PJ, Schettle SD, Stulak JM, Clavell AL, Kushwaha SS, Behfar A, Rosenbaum AN. Interventricular-Septal Output While Supported on Left Ventricular Assist Device Therapy. ASAIO J 2023; 69:424-428. [PMID: 36730725 DOI: 10.1097/mat.0000000000001851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The effects of left ventricular unloading on septal function in patients with left ventricular assist devices (LVADs) have not been well characterized in vivo. The purpose of this study was to evaluate the relationship between markers of septal function with echocardiography in relationship to RV dysfunction and late RV failure after LVAD implantation. A retrospective study was conducted of patients supported on centrifugal-flow LVADs implanted over a 10-year period. Echocardiographic data were collected pre-operatively and up to 2 years after implantation. Interventricular septum (IVS) measurements were taken at end-systole and end-diastole. Interventricular-septal output (ISO) was calculated using the formula: (IVSs-IVSd)×heart rate. A total of 110 patients were included. An immediate and sustained reduction in both lateral annulus systolic velocity (RVS') and TAPSE were observed after implant ( p < 0.0001). However, ISO gradually decreased over time ( p < 0.0001). While ISO was not predictive of late RV failure, a decrease in ISO by 25% or greater from pre-implant to hospital discharge was associated with late RV failure (OR 4.8; 95% CI, 1.4-16.5; p = 0.012) even after adjusting for relevant clinical variables ( p ≤ 0.01 for each model). RV function is known to be influenced by mechanical ventricular interdependence and we demonstrate that measurement of ISO may be a useful marker in assessing RV dysfunction and predicting RV failure in patients following LVAD implantation.
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Affiliation(s)
- Sara S Inglis
- From the Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | | | - Philip J Spencer
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Sarah D Schettle
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | | | - Atta Behfar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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13
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Rizzo SA, Yalamuri SM, Rosenbaum AN, Anavekar NS, Miranda WR, Daly R, Dearani JA, Villavicencio M, Behfar A. Percutaneous Mechanical Circulatory Support as a Bridge to Transplantation in Ebstein Anomaly. Mayo Clin Proc 2023; 98:626-630. [PMID: 37019516 DOI: 10.1016/j.mayocp.2023.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 10/26/2022] [Accepted: 01/03/2023] [Indexed: 04/07/2023]
Abstract
Ebstein anomaly is a rare congenital heart defect occurring in 0.0005% of the population because of mispositioning and malformation of the tricuspid valve. Here, we present the first description and associated imaging of percutaneous mechanical circulatory support in the setting of cardiogenic shock secondary to Ebstein anomaly.
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Affiliation(s)
- Skylar A Rizzo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Department of Molecular Pharmacology and Therapeutics, Mayo Clinic, Rochester, MN; Mayo Clinic Medical Scientist Training Program, Mayo Clinic, Rochester, MN; Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, MN
| | | | - Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, MN; William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | | | | | - Richard Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Atta Behfar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Department of Molecular Pharmacology and Therapeutics, Mayo Clinic, Rochester, MN; Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, MN; William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN.
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14
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Young KA, Lyle M, Rosenbaum AN, Chang IC, Lin G, Bois MC, Ezzeddine OFA, Jouni H, Chareonthaitawee P, Kapa S, Grogan M, Cooper LT, Blauwet L, Bois JP. 18F-FDG/ 13N-ammonia cardiac PET findings in ATTR cardiac amyloidosis. J Nucl Cardiol 2023; 30:726-735. [PMID: 35084701 DOI: 10.1007/s12350-021-02886-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 10/29/2021] [Indexed: 12/19/2022]
Abstract
18F-flurodeoxyglycose (FDG)/13N-ammonia positron emission tomography/computed tomography (PET/CT) is frequently utilized to evaluate cardiac sarcoidosis (CS) but findings can reflect other forms of myocardial inflammation or altered myocardial metabolic activity. Herein, we present five cases where cardiac PET findings suggested CS, but right ventricular endomyocardial biopsy samples revealed ATTR-type cardiac amyloidosis.
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Affiliation(s)
- Kathleen A Young
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Melissa Lyle
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FLa, USA
| | - Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Ian C Chang
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Grace Lin
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Melanie C Bois
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Omar F Abou Ezzeddine
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Hayan Jouni
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | | | - Suraj Kapa
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Martha Grogan
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FLa, USA
| | | | - John P Bois
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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15
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Mohananey A, Tseng AS, Julakanti RR, Gonzalez-Bonilla HM, Kruisselbrink T, Prochnow C, Rodman S, Lin G, Redfield MM, Rosenbaum AN, Pereira NL. An intervention strategy to improve genetic testing for dilated cardiomyopathy in a heart failure clinic. Genet Med 2023; 25:100341. [PMID: 36472615 DOI: 10.1016/j.gim.2022.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Despite its clinical implications in screening and therapy, genetic testing in dilated cardiomyopathy (DCM) is underused. This study evaluated implementing a practice intervention in a heart failure clinic to automate and streamline the process of genetic testing. METHODS Eligible patients with DCM were compared for frequency of pretest genetic education and testing during pre- and postintervention periods. The intervention comprised automated prescheduling of a cardiovascular genomics e-consult that served as a placeholder for downstream, pretest education, testing, and post-test review of genetic results. RESULTS Patients with DCM were more likely to undergo pretest genetic education after intervention than before intervention (33.5% vs 14.8%, P < .0001). Similarly, patients with DCM were more likely to undergo genetic testing after intervention than before intervention (27.3% vs 13.0%, P = .0006). The number of patients who were diagnosed to have likely pathogenic or pathogenic genetic variants were 2 of 21 (9.5%) and 6 of 53 (11.1%) before and after intervention, respectively, and variants were present in the following genes: FLNC, TTN, DES, LMNA, PLN, and TNNT2. CONCLUSION An intervention strategy in a heart failure clinic to increase the rates of pretest genetic education and testing in eligible patients with DCM was feasible and efficacious and may have important implications for the management of DCM.
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Affiliation(s)
- Akanksha Mohananey
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Andrew S Tseng
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Raghav R Julakanti
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | | | - Teresa Kruisselbrink
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Carri Prochnow
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Sandra Rodman
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Grace Lin
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Margaret M Redfield
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Naveen L Pereira
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN; Department of Molecular Pharmacology and Experimental Therapeutics, Rochester, MN.
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16
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Vollmer NJ, Wittwer ED, Rosenbaum AN, Wieruszewski PM. Procainamide pharmacokinetics during extracorporeal membrane oxygenation. Perfusion 2023; 38:409-413. [PMID: 34617854 DOI: 10.1177/02676591211050606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Procainamide is a useful agent for management of ventricular arrhythmia, however its disposition and appropriate dosing during extracorporeal membrane oxygenation (ECMO) is unknown. We report experience with continuous procainamide infusion in a critically ill adult requiring venoarterial ECMO for incessant ventricular tachycardia. Pharmacokinetic analysis of procainamide and its metabolite, N-acetylprocainamide (NAPA), was performed using serum and urine specimens. Kidney function was preserved, and sequencing of the N-acetyltransferase 2 gene revealed the patient was a phenotypic slow acetylator. Procainamide volume of distribution and half-life were calculated and found to be similar to healthy individuals. However, despite elevated serum procainamide concentrations, NAPA concentrations remained far lower in the serum and urine. The magnitude of procainamide and NAPA discordance suggested alternative contributors to the deranged pharmacokinetic profile, and we hypothesized NAPA sequestration by the ECMO circuit. Ultimately, the patient received orthotopic cardiac transplantation and was discharged home in stable condition. Procainamide should be used cautiously during ECMO, with close therapeutic drug monitoring of serum procainamide and NAPA concentrations. The achievement of therapeutic NAPA concentrations while maintaining safe serum procainamide concentrations during ECMO support may be challenging.
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Affiliation(s)
| | - Erica D Wittwer
- Department of Anesthesiology and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA.,Department of Anesthesiology and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Laboratory, Mayo Clinic, Rochester, MN, USA
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17
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Goodman D, Stulak J, Rosenbaum AN. Left ventricular assist devices: A historical perspective at the intersection of medicine and engineering. Artif Organs 2022; 46:2343-2360. [PMID: 35929377 DOI: 10.1111/aor.14371] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/06/2022] [Accepted: 07/18/2022] [Indexed: 11/26/2022]
Abstract
Over the last half-century, left ventricular assist device (LVAD) technology has progressed from conceptual therapy for failed cardiopulmonary bypass weaning to an accepted destination therapy for advanced heart failure. The history of LVAD engineering is defined by an initial development phase, which demonstrated the feasibility of such an approach, to the more recent three major generations of commercial devices. In this review, we explore the engineering challenges of LVADs, how they were addressed over time, and the clinical outcomes that resulted from each major technological development. The first generation of commercial LVADs were pulsatile devices, which lacked the appropriate durability due to their number of moving components and hemocompatibility. The second generation of LVADs was defined by replacement of complex, pulsatile pumps with primarily axial, continuous-flow systems with an impeller in the blood passageway. These devices experienced significant commercial success, but the presence of excessive trauma to the blood and in-situ bearing resulted in an unacceptable burden of adverse events. Third generation centrifugal-flow pumps use magnetically suspended rotors within the pump chamber. Superior outcomes with this newest generation of devices have been observed, particularly with respect to hemocompatibility-related adverse events including pump thrombosis, with fully magnetically levitated devices. The future of LVAD engineering includes wireless charging foregoing percutaneous drivelines and more advanced pump control mechanisms, including synchronization of the pump flow with the native cardiac cycle, and varying pump output based on degree of physical exertion using sensor or advanced device-level data triggers.
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Affiliation(s)
- Daniel Goodman
- College of Osteopathic Medicine, Des Moines University, Des Moines, Iowa, USA
| | - John Stulak
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew N Rosenbaum
- Department of Cardiovascular Diseases, Mayo Clinic Minnesota, Rochester, Minnesota, USA
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18
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Shabtaie SA, Sehrawat O, Lee JZ, Cha Y, Mulpuru SK, Kowlgi NG, Siontis KC, Rosenbaum AN, Bois JP, AbouEzzeddine OF, Noseworthy PA, Asirvatham SJ, DeSimone CV, Deshmukh AJ. Cardiac Resynchronization Therapy Response in Cardiac Sarcoidosis. J Cardiovasc Electrophysiol 2022; 33:2072-2080. [DOI: 10.1111/jce.15631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/25/2022] [Accepted: 05/11/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Samuel A. Shabtaie
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | - Ojasav Sehrawat
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | - Justin Z. Lee
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | - Yong‐Mei Cha
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | - Siva K. Mulpuru
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | - Narayan G. Kowlgi
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | | | - Andrew N. Rosenbaum
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | - John P. Bois
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | - Omar F. AbouEzzeddine
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | - Peter A. Noseworthy
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | - Samuel J. Asirvatham
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | | | - Abhishek J. Deshmukh
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
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19
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Jentzer JC, Reddy YN, Rosenbaum AN, Dunlay SM, Borlaug BA, Hollenberg SM. Outcomes and predictors of mortality among cardiac intensive care unit patients with heart failure. J Card Fail 2022; 28:1088-1099. [DOI: 10.1016/j.cardfail.2022.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/08/2022] [Accepted: 02/09/2022] [Indexed: 12/11/2022]
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20
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Kolluri N, Schmidt TJ, Elwazir MY, Kapa S, Abou Ezzeddine OF, Bois JP, Schirger JA, Rosenbaum AN, Cooper LT. Routine Laboratory Biomarkers As Prognostic Indicators of Cardiac Sarcoidosis Outcomes. Sarcoidosis Vasc Diffuse Lung Dis 2022; 39:e2022023. [PMID: 36791034 PMCID: PMC9766851 DOI: 10.36141/svdld.v39i2.11136] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 06/19/2022] [Indexed: 02/16/2023]
Abstract
Background Biomarkers to monitor disease activity and predict major adverse cardiac events (MACE) in CS have not been described previously. We aimed to identify biomarkers to predict MACE in cardiac sarcoidosis (CS). Methods Patients (N=232) diagnosed with CS were retrospectively enrolled. Biomarkers including angiotensin-converting enzyme (ACE), N-terminal brain natriuretic peptide (NT-proBNP), troponin T, and creatinine levels were evaluated against a primary end point of left ventricular assist device implantation, heart transplantation, or death, and a secondary end point of cardiac hospitalization-free survival. Results Troponin T (hazard ratio [HR], 1.06 per 0.01 ng/mL; P=.006), NT-proBNP (HR, 1.31 per 1,000 pg/mL; P<.001), and creatinine (HR, 4.02 per mg/dL; P=.01) were associated with the primary end point, even after adjusting for ejection fraction. NT-proBNP, B-type natriuretic peptide (BNP), creatinine, albumin, and calcium were associated with the secondary end point (P<.05). ACE levels were associated with presence of late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) imaging (mean difference, 14.7; P=.03); 1,25 dihydroxyvitamin D (1,25-OHVit-D) was associated with uptake on cardiac 18F-flurodeoxyglucose position emission tomography (FDG-PET, P=.03). Conclusions Troponin T, NT-proBNP, and creatinine predict clinically significant outcomes in CS. ACE levels correlated with LGE on CMR, and 1,25-OHVit-D levels correlated with FDG-PET activity.
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Affiliation(s)
- Nikhil Kolluri
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | | | - Suraj Kapa
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - John P. Bois
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - John A. Schirger
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, Mayo Clinic William J. von Liebig Center for Transplantation and Clinical Registration Mayo Clinic, Rochester, MN
| | | | - Leslie T. Cooper
- Department of Cardiovascular Medicine (Dr Cooper), Mayo Clinic, Jacksonville, FL
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21
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Rosenbaum AN, Antaki JF, Behfar A, Villavicencio MA, Stulak J, Kushwaha SS. Physiology of Continuous-Flow Left Ventricular Assist Device Therapy. Compr Physiol 2021; 12:2731-2767. [PMID: 34964115 DOI: 10.1002/cphy.c210016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The expanding use of continuous-flow left ventricular assist devices (CF-LVADs) for end-stage heart failure warrants familiarity with the physiologic interaction of the device with the native circulation. Contemporary devices utilize predominantly centrifugal flow and, to a lesser extent, axial flow rotors that vary with respect to their intrinsic flow characteristics. Flow can be manipulated with adjustments to preload and afterload as in the native heart, and ascertainment of the predicted effects is provided by differential pressure-flow (H-Q) curves or loops. Valvular heart disease, especially aortic regurgitation, may significantly affect adequacy of mechanical support. In contrast, atrioventricular and ventriculoventricular timing is of less certain significance. Although beneficial effects of device therapy are typically seen due to enhanced distal perfusion, unloading of the left ventricle and atrium, and amelioration of secondary pulmonary hypertension, negative effects of CF-LVAD therapy on right ventricular filling and function, through right-sided loading and septal interaction, can make optimization challenging. Additionally, a lack of pulsatile energy provided by CF-LVAD therapy has physiologic consequences for end-organ function and may be responsible for a series of adverse effects. Rheological effects of intravascular pumps, especially shear stress exposure, result in platelet activation and hemolysis, which may result in both thrombotic and hemorrhagic consequences. Development of novel solutions for untoward device-circulatory interactions will facilitate hemodynamic support while mitigating adverse events. © 2021 American Physiological Society. Compr Physiol 12:1-37, 2021.
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Affiliation(s)
- Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - James F Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, USA
| | - Atta Behfar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA.,VanCleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sudhir S Kushwaha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
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22
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Kassi M, Rosenbaum AN, El Sabbagh A, Boilson B, Behfar A. Hemodynamic Assessment of Dual Obstructive Left Ventricular Assist Device Lesions. Cureus 2021; 13:e17180. [PMID: 34548982 PMCID: PMC8437207 DOI: 10.7759/cureus.17180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 08/14/2021] [Indexed: 11/05/2022] Open
Abstract
Obstructive left ventricular assist device (LVAD) lesions are uncommon but are being increasingly recognized, particularly with the increased use of advanced imaging modalities. While heart failure symptoms and LVAD power fluctuations have a broad differential, obstructive lesions in the LVAD circuit should be considered. We present a unique case of a patient supported on HeartWare HVAD (Medtronic Inc., Dublin, Ireland) therapy, who experienced postural dizziness with objective orthostatic hypotension and occasional ventricular tachycardia. With fluctuations in LVAD flow and power, a CT scan with three-dimensional reconstruction was obtained showing outflow graft kinking. The patient was brought to the cardiac catheterization laboratory for investigation and consideration of outflow graft intervention. However, intracardiac echocardiography revealed the presence of an inflow cannula obstruction with position changes and catheter interrogation involving the outflow cannula suggestive of a gradient across the kinked area as an unlikely cause for the presentation. This case highlights the importance of a thorough interrogation for obstructive lesions in the setting of heart failure symptoms, particularly postural symptoms, in a patient on LVAD therapy, even when not identified on routine echocardiography.
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Affiliation(s)
- Mahwash Kassi
- Department of Cardiology, Houston Methodist, Houston, USA
| | | | | | - Barry Boilson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, USA
| | - Atta Behfar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, USA
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23
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Kolluri N, Elwazir MY, Rosenbaum AN, Maklady FA, AbouEzzeddine OF, Kapa S, Blauwet LA, Chareonthaitawee P, McBane RD, Bois JP. Effect of Corticosteroid Therapy in Patients With Cardiac Sarcoidosis on Frequency of Venous Thromboembolism. Am J Cardiol 2021; 149:112-118. [PMID: 33757783 DOI: 10.1016/j.amjcard.2021.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/06/2021] [Accepted: 03/12/2021] [Indexed: 01/30/2023]
Abstract
Sarcoidosis is a multisystem inflammatory condition with occasional cardiac involvement (CS), which may be associated with risk of venous thromboembolism (VTE). As data on VTE in CS are sparse and corticosteroid therapy has not been previously examined, we aim to determine the association between CS, corticosteroid treatment for CS, and VTE. Patients referred to our institution with concern for sarcoidosis and underwent a positron emission tomography (PET) scan were retrospectively assessed. Chi-squared and multivariate regression analyses were conducted to determine the association between a diagnosis of sarcoidosis, CS, corticosteroid use, and VTE events. Six hundred and forty nine patients were split into 3 categories: 235 with no sarcoidosis (NS), 91 with extra-cardiac sarcoidosis only (ECS), and 323 with CS (isolated CS and/or CS with extra cardiac sarcoid). Thirty nine CS, 7 ECS, and 9 NS patients developed PE while 44 CS, 3 ECS, and 18 NS patients developed DVT. On multivariate regression, neither CS nor ECS was an independent risk factor for VTE (p >0.05) but corticosteroid use was independently associated with VTE (HR 3.06, p = 0.007 for PE, HR 6.21, p <0.0001 for DVT). On logistic regression analysis, corticosteroid dose was found to be independently associated with both PE (p = 0.001) and DVT (p = 0.007). Optimal threshold for defining VTE risk with corticosteroid therapy was a prednisone-equivalent dose of 17.5 mg. In conclusion, contrary to previous studies, this current study found that neither sarcoidosis nor CS is an independent risk factor for VTE. Rather, corticosteroid therapy was associated with an increased risk of VTE.
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24
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Schmidt TJ, Rosenbaum AN, Kolluri N, Stulak JM, Daly RC, Schirger JA, Elwazir MY, Kapa S, Cooper LT, Blauwet LA. Natural History of Patients Diagnosed with Cardiac Sarcoidosis at Left Ventricular Assist Device Implantation or Cardiac Transplantation. ASAIO J 2021; 67:583-587. [PMID: 33902104 DOI: 10.1097/mat.0000000000001262] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 12/28/2022] Open
Abstract
To our knowledge, natural history has not been reported for cardiac sarcoidosis (CS) diagnosed by pathologic evaluation of the apical core at left ventricular assist device (LVAD) implantation or cardiac transplantation. We retrospectively identified 232 consecutive patients meeting CS criteria. Of these patients, 54 were diagnosed by pathologic confirmation of CS, 10 after evaluation of the apical core (LVAD implant) or explanted heart (transplant). We compared clinical characteristics at initial evaluation and outcomes for these 10 patients with those of 10 patients with known CS before LVAD implant/transplant. In the study group, five patients (50%) had confirmed extracardiac sarcoidosis before LVAD implant/transplant; five had not been diagnosed with sarcoidosis. Mean (standard deviation) left ventricular ejection fraction at initial evaluation was 23% (16%), and left ventricular end-diastolic dimension was 61 (10) mm. Four patients died during follow-up; however, no survival difference was found for the 10 patients diagnosed incidentally and the group with a previous diagnosis or institutional LVAD/transplant cohorts. Patients diagnosed with CS on pathological examination of the apical core/explanted heart may have severe dilated cardiomyopathy as the initial presentation. Outcomes for patients with CS after advanced heart failure therapies may be comparable with those of non-CS patients.
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Affiliation(s)
| | | | | | - John M Stulak
- Department of Cardiovascular Surgery
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | - Richard C Daly
- Department of Cardiovascular Surgery
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | - John A Schirger
- Department of Cardiovascular Medicine
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | | | | | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida
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25
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Rosenbaum AN, Kolluri N, Elwazir MY, Kapa S, Abou Ezzeddine OF, Bois JP, Chareonthaitawee P, Schmidt TJ, Cooper LT. Identification of a novel presumed cardiac sarcoidosis category for patients at high risk of disease. Int J Cardiol 2021; 335:66-72. [PMID: 33878372 DOI: 10.1016/j.ijcard.2021.04.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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: 10/02/2020] [Revised: 02/19/2021] [Accepted: 04/12/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Histologic evidence is required for a definitive diagnosis of cardiac sarcoidosis (CS) by published guidelines; however, the sporadic nature of the disease may produce false negative biopsy results, causing CS to be underdiagnosed. We sought to establish a clinical category of CS absent histologic findings. METHODS Patients evaluated for CS were stratified into 3 groups: probable CS and definite CS based on Heart Rhythm Society (HRS) criteria and presumed CS, ie, patients without any histologic evidence of sarcoidosis, but with unexplained high-grade atrioventricular block or ventricular arrhythmia and findings suggestive of CS on either cardiac magnetic resonance imaging or positron emission tomography. The primary end point was hospitalization-free and overall survival at 10 years. RESULTS A total of 383 patients were included in the study: 59, definite CS; 223, probable CS; and 101, presumed CS (62, isolated CS and 39, systemic CS). Compared with patients meeting HRS criteria for CS, patients with presumed CS had lower odds of New York Heart Association class III or IV symptoms (odds ratio [OR], 0.44 [95% CI, 0.23-0.83]; P = .01) but greater odds of previous ventricular tachycardia (OR, 2.4 [95% CI, 1.4-4.0]; P = .001) or history of resuscitated sudden cardiac arrest (OR, 2.9 [95% CI, 1.0-8.6]; P = .05). Hospitalization-free and overall survival were similar among groups (P = .51 and P = .71, respectively). CONCLUSIONS Clinical categorization of patients with presumed CS identified a high-risk cohort comparable to patients with histologic evidence of disease, although caution should be exercised in reaching this diagnosis without paying due diligence to the differential diagnosis.
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Affiliation(s)
- Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States.
| | - Nikhil Kolluri
- Department of Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States
| | | | - Suraj Kapa
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States
| | - Omar F Abou Ezzeddine
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States
| | - John P Bois
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States
| | | | - Tyler J Schmidt
- Department of Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States
| | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, United States
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Sabbah MS, Rosenbaum AN, Behfar A. Listening for Thrombosis. Mayo Clin Proc 2021; 96:841-843. [PMID: 33814088 DOI: 10.1016/j.mayocp.2021.02.021] [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: 02/16/2021] [Accepted: 02/23/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Michael S Sabbah
- Department of Cardiovascular Diseases, Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, MN
| | - Andrew N Rosenbaum
- von Liebig Center for Transplantation and Clinical Regeneration, Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, MN
| | - Atta Behfar
- Department of Cardiovascular Diseases, von Liebig Center for Transplantation and Clinical Regeneration, Department of Molecular Pharmacology and Experimental Therapeutics, Van Cleve Cardiac Regenerative Medicine Program, Mayo Clinic, Rochester, MN.
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Daly RC, Rosenbaum AN, Dearani JA, Clavell AL, Pereira NL, Boilson BA, Frantz RP, Behfar A, Dunlay SM, Rodeheffer RJ, Schirger JA, Taner T, Gandhi MJ, Heimbach JK, Rosen CB, Edwards BS, Kushwaha SS. Heart-After-Liver Transplantation Attenuates Rejection of Cardiac Allografts in Sensitized Patients. J Am Coll Cardiol 2021; 77:1331-1340. [PMID: 33706876 DOI: 10.1016/j.jacc.2021.01.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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: 10/14/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND In patients undergoing heart transplantation, significant allosensitization limits access to organs, resulting in longer wait times and high waitlist mortality. Current desensitization strategies are limited in enabling successful transplantation. OBJECTIVES The purpose of this study was to describe the cumulative experience of combined heart-liver transplantation using a novel heart-after-liver transplant (HALT) protocol resulting in profound immunologic protection. METHODS Reported are the results of a clinical protocol that was instituted to transplant highly sensitized patients requiring combined heart and liver transplantation at a single institution. Patients were dual-organ listed with perceived elevated risk of rejection or markedly prolonged waitlist time due to high levels of allo-antibodies. Detailed immunological data and long-term patient and graft outcomes were obtained. RESULTS A total of 7 patients (age 43 ± 7 years, 86% women) with high allosensitization (median calculated panel reactive antibody = 77%) underwent HALT. All had significant, unacceptable donor specific antibodies (DSA) (>4,000 mean fluorescence antibody). Prospective pre-operative flow cytometric T-cell crossmatch was positive in all, and B-cell crossmatch was positive in 5 of 7. After HALT, retrospective crossmatch (B- and T-cell) became negative in all. DSA fell dramatically; at last follow-up, all pre-formed or de novo DSA levels were insignificant at <2,000 mean fluorescence antibody. No patients experienced >1R rejection over a median follow-up of 48 months (interquartile range: 25 to 68 months). There was 1 death due to metastatic cancer and no significant graft dysfunction. CONCLUSIONS A heart-after-liver transplantation protocol enables successful transplantation via near-elimination of DSA and is effective in preventing adverse immunological outcomes in highly sensitized patients listed for combined heart-liver transplantation.
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Affiliation(s)
- Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Alfredo L Clavell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Naveen L Pereira
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Barry A Boilson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert P Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Atta Behfar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA; VanCleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Shannon M Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA; Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Richard J Rodeheffer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - John A Schirger
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Timucin Taner
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Immunology, Mayo Clinic, Rochester, Minnesota, USA
| | - Manish J Gandhi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Charles B Rosen
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Brooks S Edwards
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Sudhir S Kushwaha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA.
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Rosenbaum AN, Ternus BW, Jentzer JC. Liver Dysfunction: Guilty by Association. Ann Thorac Surg 2021; 112:1381. [PMID: 33571497 DOI: 10.1016/j.athoracsur.2020.11.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/18/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
| | - Bradley W Ternus
- Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin, Madison, Madison, Wisconsin
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Rosenbaum AN, Clavell AL, Stulak JM, Behfar A. Correction of High Afterload Improves Low Cardiac Output in Patients Supported on Left Ventricular Assist Device Therapy. ASAIO J 2021; 67:32-38. [PMID: 32224784 DOI: 10.1097/mat.0000000000001159] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
There is a paucity of data describing the invasive assessment of afterload and influence on cardiac output in patients supported on left ventricular assist device (LVAD) therapy. From 2015 to 2018, patients on LVAD therapy were evaluated with simultaneous left/right heart catheterization ramp study for speed optimization. Hemodynamic parameters from 31 patients without significant aortic insufficiency were analyzed. Mean central aortic pressure (MAP) was elevated at 87 ± 13 mm Hg at baseline. No direct association between MAP and cardiac index (CI) was found (r = 0.11, p = 0.20). However, variable MAP provided vastly different patterns of cardiac output response to speed increments (positive correlation, p = 0.047 for MAP <80 mm Hg; negative trend, p = 0.25 for MAP > 100 mm Hg). Patients noted to be hypertensive (MAP > 90, n = 8) received nitrate therapy and experienced both improvement in biventricular filling pressures and a mean increase in CI from 2.4 to 2.9 L/min/m2 (+22%, p = 0.04) at a fixed revolutions per minute. High afterload is common in patients on LVAD therapy, is associated with poor response to ramp, and is ameliorated by nitrates. These findings serve as a foundation to evaluate the dynamic effects of high afterload and chronic vasodilator therapy in patients with durable LVADs.
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Affiliation(s)
| | - Alfredo L Clavell
- From the Department of Cardiovascular Diseases
- William J von Liebig Center for Transplantation and Clinical Regeneration
| | | | - Atta Behfar
- From the Department of Cardiovascular Diseases
- William J von Liebig Center for Transplantation and Clinical Regeneration
- VanCleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota
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30
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Rosenbaum AN, Bohman JK, Rehfeldt KH, Stulak JM, Daly RC, Klompas AM, Behfar A, Yalamuri SM. Dual RVAD-ECMO Circuits to Treat Cardiogenic Shock and Hypoxemia Due to Necrotizing Lung Infection: A Case Report. A A Pract 2020; 14:e01181. [PMID: 32224696 DOI: 10.1213/xaa.0000000000001181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Utilization of venoarterial extracorporeal membrane oxygenation (VA-ECMO) is expanding, but dual VA-ECMO circuits to treat cardiogenic shock with refractory hypoxemia is unreported. We describe the case of combined cardiogenic and distributive shock due to necrotizing pulmonary blastomycosis. After initial central VA-ECMO cannulation, acute respiratory distress syndrome (ARDS) with increasing shunt resulted in significant central hypoxemia due to progressive ventilation-perfusion mismatch. An additional circuit provided complete oxygenation of the high circulating volume. After 4 months on support, he underwent successful heart-lung-kidney transplantation. Dual ECMO circuits are technically feasible and may be advantageous in specific circumstances of high pulmonary shunting resulting in excessive hypoxemia unbalanced with appropriate oxygen delivery.
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Affiliation(s)
| | - John K Bohman
- Department of Anesthesiology and Perioperative Medicine
| | | | | | | | | | - Atta Behfar
- From the Department of Cardiovascular Diseases.,William J. von Liebig Center for Transplantation and Clinical Regeneration.,VanCleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota
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Rosenbaum AN, Ternus BW, Pahwa S, Stulak JM, Clavell AL, Schettle SD, Behfar A, Jentzer JC. Risk of Liver Dysfunction After Left Ventricular Assist Device Implantation. Ann Thorac Surg 2020; 111:1961-1967. [PMID: 33058819 DOI: 10.1016/j.athoracsur.2020.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/21/2020] [Accepted: 08/05/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Incident liver dysfunction after left ventricular assist device implantation has been previously associated with adverse outcomes, yet data on perioperative risk markers are sparse. METHODS We retrospectively reviewed consecutive patients undergoing continuous-flow left ventricular assist device implant between 2007 and 2017 at a single institution. Perioperative variables were evaluated by univariate modeling and adjusted for false discovery rate. Variables most significantly associated with incident Interagency Registry for Mechanically Assisted Circulatory Support-defined liver dysfunction (INT-LD) were evaluated using logistic regression and optimal cutpoints were defined. One-year survival was evaluated using Kaplan-Meier analysis. RESULTS We included 359 patients (79% male; mean age 59 ± 13 years; 46% ischemic; 64% destination therapy). Lower right ventricular stroke work index at the time of right heart catheterization, higher right atrial pressure 6 hours after right heart catheterization, higher preoperative total bilirubin, longer cardiopulmonary bypass time, and greater volume of intraoperative ultrafiltration were most strongly associated with incident INT-LD (adjusted P < .01 for each). Initial right ventricular stroke work index less than 460 mm Hg∗mL/m2 (odds ratio [OR] 4.6; 95% confidence interval [CI], 2.3 to 9.4), 6-hour right heart catheterization 14 mm Hg or greater (OR 4.3; 95% CI, 2.1 to 8.8), cardiopulmonary bypass time longer than 137 minutes (OR 3.3; 95% CI, 1.8 to 6.2; P < .01 for all), ultrafiltration more than 2.95 L (OR 3.7; 95% CI, 2 to 6.8), and total bilirubin greater than 1.4 mg/dL (OR 2.7; 95% CI, 1.4 to 5) were each strongly associated with risk of INT-LD, which was associated with decreased unadjusted 1-year survival (P < .001). CONCLUSIONS Right ventricular stroke work index, right heart catheterization, cardiopulmonary bypass time, and ultrafiltration were each more strongly associated with elevated risk of INT-LD after left ventricular assist device implant than total bilirubin. Therefore, optimization of right ventricular hemodynamics and minimizing cardiopulmonary bypass time and ultrafiltration could potentially reduce the risk of liver dysfunction, but these observations require prospective validation.
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Affiliation(s)
- Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin, Madison, Wisconsin.
| | - Bradley W Ternus
- Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin, Madison, Wisconsin
| | - Siddharth Pahwa
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Alfredo L Clavell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | - Sarah D Schettle
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Atta Behfar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota; VanCleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Snipelisky D, Fudim M, Perez A, Nayor M, Lever NM, Raymer DS, Rosenbaum AN, AbouEzzeddine O, Hernandez AF, Stevenson LW, Gilstrap LG. Expected vs Actual Outcomes of Elective Initiation of Inotropic Therapy During Heart Failure Hospitalization. Mayo Clinic Proceedings: Innovations, Quality & Outcomes 2020; 4:529-536. [PMID: 33083701 PMCID: PMC7557209 DOI: 10.1016/j.mayocpiqo.2020.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objective To describe the intent and early outcomes of elective inotrope use during heart failure hospitalization. Patients and Methods A prospective multisite design was used to collect data for hemodynamically stable patients started electively on inotrope therapy between January 1 and August 31, 2018. We prospectively recorded data when intravenous inotropic therapy was initiated, including survey of the attending cardiologists regarding expectations for the clinical course. Patients were followed up for events through hospital discharge and an additional survey was administered at the end of hospitalization. Results For the 92 patients enrolled, average age was 60 years and ejection fraction was 24%±12%. At the time of inotrope initiation, attending heart failure cardiologists predicted that 50% (n=46) of the patients had a “high or very high” likelihood of becoming dependent on intravenous inotropic therapy and 58% (n=53) had a “high” likelihood of death, transplant, or durable ventricular assist device placement within the next 6 months. Provider predictions regarding death/hospice or need for continued home infusions were accurate only 51% (47 of 92) of the time. Only half the patients (n=47) had goals-of-care conversations before inotrope treatment initiation. Conclusion More than half the patients (51 of 92) electively started on inotrope treatment without present or imminent cardiogenic shock ultimately required home inotrope therapy, died during admission, or were discharged with hospice. Heart failure clinicians could not reliably identify those patients at the time of inotrope therapy initiation and goals-of-care discussions were not frequently performed.
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Rosenbaum AN, Stulak JM, Clavell AL, Behfar A. Inadequate left ventricular unloading during ramp is associated with hospitalization or death during left ventricular assist device support. Artif Organs 2020; 45:115-123. [PMID: 32761951 DOI: 10.1111/aor.13792] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/23/2020] [Accepted: 07/28/2020] [Indexed: 12/26/2022]
Abstract
A combined right and left-sided heart catheterization (RHC/LHC) protocol was recently reported to optimize patients supported by left ventricular assist device (LVAD). Using this platform, we sought to evaluate the prognostic significance of several hemodynamic indices, including left ventricular end-diastolic pressure (LVEDP) and transaortic gradient (peak aortic pressure - peak left ventricular pressure in systole, TAG). We evaluated all patients undergoing RHC/LHC at our institution from 2015 through 2018, and comprehensive clinical data were obtained. Primary end points were (1) a composite outcome that included hospitalization or death and (2) 1-year overall survival after catheterization. Forty-two patients were included in the analysis. Optimization resulted in normalization of hemodynamic parameters; all variables were significantly improved from baseline (P ≤ .05). On univariate modeling, final LVEDP was associated with the primary end point (hazard ratio [HR], 1.2 per 1-mm Hg increase; 95% CI, 1.1-1.3; P = .002). After adjusting for LVAD speed, TAG, and cardiac index in a multivariate model, the association between LVEDP and the composite end point remained significant (HR, 1.2 per 1-mm Hg increase; 95% CI, 1.1-1.4; P = .001). In the setting of LVAD support, inadequate LV unloading was a significant marker of poor outcomes with time, suggesting that LVEDP is a central prognostic marker in this population.
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Affiliation(s)
- Andrew N Rosenbaum
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MI, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MI, USA
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MI, USA
| | - Alfredo L Clavell
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MI, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MI, USA
| | - Atta Behfar
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MI, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MI, USA
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Koerber DM, Rosenbaum AN, Olson TP, Kushwaha S, Stulak J, Maltais S, Behfar A. Exercise-induced hypoxemia predicts heart failure hospitalization and death in patients supported with left ventricular assist devices. Int J Artif Organs 2019; 43:165-172. [PMID: 31630619 DOI: 10.1177/0391398819882435] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Following implantation of continuous-flow left ventricular assist devices, mechanical off-loading results in improved resting hemodynamics; however, peak exercise capacity generally does not increase substantially. This study evaluated patients supported by continuous-flow left ventricular assist devices who were invasively monitored during exercise to define parameters that underpin exercise capacity and outcomes. A review of all patients supported by continuous-flow left ventricular assist devices who underwent supine bicycle ergometry exercise testing with measurement of pulmonary gas exchange during right heart catheterization for evaluation of dyspnea at one institution between 2007 and 2018 was performed (n = 22). The primary outcome of this investigation was death or heart failure hospitalization. Although resting filling pressures were relatively preserved, resting cardiac index (Fick) was low (2.1 ± 0.5 mL/kg/min). An impaired cardiac output reserve was present in 75% of patients. On univariate modeling, patients with supine exercise-induced hypoxemia (O2 saturation <90%) experienced significantly diminished hospitalization-free survival (unadjusted hazard ratio = 11.0, confidence interval = 2.4-57.2, p = 0.003), which persisted despite adjustment for right heart catheterization peak VO2 and peak cardiac output (adjusted hazard ratio = 25, confidence interval = 3.6-322, p = 0.001). Our findings suggest that supine exercise testing provides additional prognostic utility in the continuous-flow left ventricular assist device population.
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Affiliation(s)
- Daniel M Koerber
- Van Cleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Thomas P Olson
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Sudhir Kushwaha
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.,William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Simon Maltais
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Atta Behfar
- Van Cleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.,William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
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Abstract
Given the global burden of heart failure, strategies to understand the underlying cause or to provide prognostic information are critical to reducing the morbidity and mortality associated with this highly prevalent disease. Cardiomyopathies often have a genetic cause, and the field of heart failure genetics is progressing rapidly. Through a deliberate investigation, evaluation for a familial component of cardiomyopathy can lead to increased identification of pathogenic genetic variants. Much research has also been focused on identifying markers of risk in patients with cardiomyopathy with the use of genetic testing. Advances in our understanding of genetic variants have been slightly offset by an increased recognition of the heterogeneity of disease expression. Greater breadth of genetic testing can increase the likelihood of identifying a variant of uncertain significance, which is resolved only rarely by cellular functional validation and segregation analysis. To increase the use of genetics in heart failure clinics, increased availability of genetic counsellors and other providers with experience in genetics is necessary. Ultimately, through ongoing research and increased clinical experience in cardiomyopathy genetics, an improved understanding of the disease processes will facilitate better clinical decision-making about the therapies offered, exemplifying the implementation of precision medicine.
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Affiliation(s)
| | - Katherine E Agre
- Department of Clinical Genomics, Mayo Clinic, Rochester, MN, USA
| | - Naveen L Pereira
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA. .,William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA. .,Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA.
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Rosenbaum AN, Bois MC, Zhang X, Santivasi WL, Freeman WK. Primary Malignant Pericardial Mesothelioma: A Clinical Case Series Illustrating the Necessity of a Multidisciplinary Approach. JACC Case Rep 2019; 1:202-207. [PMID: 34316785 PMCID: PMC8301520 DOI: 10.1016/j.jaccas.2019.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/11/2019] [Accepted: 06/19/2019] [Indexed: 11/23/2022]
Abstract
Primary malignant pericardial mesothelioma is a rare cardiac neoplasm. The authors evaluated risk factors, clinical presentation, and outcomes by reviewing all biopsy-confirmed cases at one institution. The use of multimodality imaging, detailed hemodynamic assessment for the presence of an effusive-constrictive profile, and cytology evaluation can support the diagnosis. (Level of Difficulty: Advanced.)
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Affiliation(s)
- Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Melanie C Bois
- Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, Minnesota
| | - Xin Zhang
- Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Wil L Santivasi
- Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - William K Freeman
- Department of Internal Medicine, Division of Cardiovascular Diseases, Mayo Clinic Arizona, Scottsdale, Arizona
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Alnsasra H, Asleh R, Schettle SD, Pereira NL, Frantz RP, Edwards BS, Clavell AL, Maltais S, Daly RC, Stulak JM, Rosenbaum AN, Behfar A, Kushwaha SS. Diastolic Pulmonary Gradient as a Predictor of Right Ventricular Failure After Left Ventricular Assist Device Implantation. J Am Heart Assoc 2019; 8:e012073. [PMID: 31411097 PMCID: PMC6759881 DOI: 10.1161/jaha.119.012073] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Diastolic pulmonary gradient (DPG) was proposed as a better marker of pulmonary vascular remodeling compared with pulmonary vascular resistance (PVR) and transpulmonary gradient (TPG). The prognostic significance of DPG in patients requiring a left ventricular assist device (LVAD) remains unclear. We sought to investigate whether pre‐LVAD DPG is a predictor of survival or right ventricular (RV) failure post‐LVAD. Methods and Results We retrospectively reviewed 268 patients who underwent right heart catheterization before LVAD implantation from 2007 to 2017 and had pulmonary hypertension because of left heart disease. Patients were dichotomized using DPG ≥7 mm Hg, PVR ≥3 mm Hg, or TPG ≥12 mm Hg. The associations between these parameters and all‐cause mortality or RV failure post LVAD were assessed with Cox proportional hazards regression and Kaplan–Meier analyses. After a mean follow‐up time of 35 months, elevated DPG was associated with increased risk of RV failure (hazard ratio [HR]: 3.30; P=0.004, for DPG ≥7 versus DPG <7), whereas elevated PVR (HR 1.85, P=0.13 for PVR ≥3 versus PVR <3) or TPG (HR 1.47, P=0.35, for TPG ≥12 versus TPG <12) were not associated with the development of RV failure. Elevated DPG was not associated with mortality risk (HR 1.16, P=0.54, for DPG ≥7 versus DPG <7), whereas elevated PVR, but not TPG, was associated with higher mortality risk (HR 1.55; P=0.026, for PVR ≥3 versus PVR <3). Conclusions Among patients with pulmonary hypertension because of left heart disease requiring LVAD support, elevated DPG was associated with RV failure but not survival, while elevated PVR predicted mortality post LVAD implantation.
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Affiliation(s)
- Hilmi Alnsasra
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | - Rabea Asleh
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | | | | | - Robert P Frantz
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | | | | | - Simon Maltais
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | - Richard C Daly
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | - John M Stulak
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | | | - Atta Behfar
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
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Julakanti RR, Rosenbaum AN, Lin G. Treatment of Growth Hormone Excess is Associated with Improvement in Abnormal Cardiac Phenotypes. J Card Fail 2019. [DOI: 10.1016/j.cardfail.2019.07.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
PURPOSE OF REVIEW The rapidly evolving field of cardiovascular genetics has already improved the care of patients with heart failure and families. The purpose of the current review is to describe the most and provide the most pertinent updates in the field of heart failure genetics. RECENT FINDINGS Recent advanced in heart failure genetics have begun to not only increase the yield of testing through improving technology and use of whole exome or whole genome screening, but also enabled the improving technology and increasing use of whole exome or whole genome screening, but also enabled an enhanced understanding of the implications of results of genetic testing. For instance, new data have described differential responses to heart failure therapies based on genetic testing. Additionally, variant analysis by locus in genetic cardiomyopathies has facilitated a much-improved prognostic understanding of phenotype. Recent years have seen advancements in the understanding of the genetics of rare disorders, including pediatric-onset cardiomyopathies, previously under-investigated; restrictive cardiomyopathies; and non-compaction cardiomyopathy. The last few years have heralded not only a broader understanding of the scope of the genetics of heart failure, but have also provided notable leaps in mechanistic and prognostic understanding, which will serve as the foundation for clinical investigation and future genetic variant assessment.
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Affiliation(s)
- Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Naveen Pereira
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. .,Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA. .,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA.
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van Zyl M, Witt CM, Bhatia S, Khasawneh M, Gaba P, Lenz CJ, Rosenbaum AN, Aung H, Hodge DO, McLeod CJ, Asirvatham SJ. Paced QRS morphology predicts incident left ventricular systolic dysfunction and atrial fibrillation. Indian Pacing Electrophysiol J 2019; 19:40-46. [PMID: 30858056 PMCID: PMC6450823 DOI: 10.1016/j.ipej.2019.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 12/12/2018] [Revised: 02/22/2019] [Accepted: 03/05/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The prognostic significance of paced QRS complex morphology on surface ECG remains unclear. This study aimed to assess long-term outcomes associated with variations in the paced QRS complex. METHODS Adult patients who underwent dual-chamber pacemaker implantation with 20% or more ventricular pacing and a 12-lead ECG showing a paced complex were included. The paced QRS was analyzed in leads I and aVL. Long-term clinical and echocardiographic outcomes were compared at 5 years. RESULTS The study included 844 patients (43.1% female; age 75.0 ± 12.1). Patients with a longer paced QRS (pQRS) duration in lead I had a lower rate of atrial fibrillation (HR 0.80; p = 0.03) and higher rate of systolic dysfunction (HR 1.17; p < 0.001). Total pacing complex (TPC) duration was linked to higher rates of ICD implantation (HR 1.18; p = 0.04) and systolic dysfunction (HR 1.22, p < 0.001). Longer paced intrinsicoid deflection (pID) was associated with less atrial fibrillation (HR 0.75; p = 0.01), more systolic dysfunction (HR 1.17; p < 0.001), ICD implantation (HR 1.23; p = 0.04), and CRT upgrade (HR 1.23; p = 0.03). Exceeding thresholds for TPC, pQRS, and pID of 170, 146, and 112 ms in lead I, respectively, was associated with a substantial increase in systolic dysfunction over 5 years (p < 0.001). CONCLUSIONS Longer durations of all tested parameters in lead I were associated with increased rates of left ventricular systolic dysfunction. ICD implantation and CRT upgrade were also linked to increased TPC and pID durations. Paradoxically, patients with longer pID and pQRS had less incident atrial fibrillation.
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Affiliation(s)
- Martin van Zyl
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Chance M Witt
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Subir Bhatia
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Majd Khasawneh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Prakriti Gaba
- Mayo Medical School, Mayo Clinic, Rochester, MN, USA
| | - Charles J Lenz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Htin Aung
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
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Rosenbaum AN, Frantz RP, Kushwaha SS, Stulak JM, Maltais S, Behfar A. Novel Left Heart Catheterization Ramp Protocol to Guide Hemodynamic Optimization in Patients Supported With Left Ventricular Assist Device Therapy. J Am Heart Assoc 2019; 8:e010232. [PMID: 30755070 PMCID: PMC6405677 DOI: 10.1161/jaha.118.010232] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 12/24/2018] [Indexed: 01/30/2023]
Abstract
Background Left ventricular (LV) hemodynamic assessment has been sparsely performed in patients supported on continuous-flow LV assist devices (cf LVADs ). Insight into dynamic changes of left heart parameters during ramp studies may improve LV assist device optimization and evaluate pathology. Methods and Results To complement right heart catheterization, a novel technique for left heart catheterization in patients with a cf LVAD was developed. Patients implanted with cf LVAD s underwent hemodynamic ramp left heart catheterization and right heart catheterization with transthoracic echocardiography. Continuous aortic and LV pressures were measured along with right atrial, pulmonary artery, and pulmonary capillary wedge pressures. A novel index, the transaortic gradient ( TAG ) was established. Thirty eight patients with cf LVADs were evaluated at a median of 446 days (interquartile range, 183-742) after device implant. During left heart catheterization performed for hemodynamic optimization, drop-in LV end-diastolic pressure and pulmonary capillary wedge pressure were associated with a rise in TAG . A range was identified for TAG (20-40 mm Hg) as providing the most optimal level of hemodynamic offloading. Pathologic states deviated from normal responses to ramp. LV assist device thrombosis was associated with an inability to increase in TAG during speed ramp. Significant aortic insufficiency was associated with a marked increase in LV end-diastolic pressure despite a concomitant decrease in pulmonary capillary wedge pressure with increasing LV assist device speeds. Conclusions Inclusion of left heart catheterization to a typical right heart catheterization LV assist device ramp protocol imparted unique insights to optimize cf LVAD speeds in different clinical scenarios. A novel index, the TAG was defined and provided additional resolution to optimized offloading.
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Affiliation(s)
| | - Robert P. Frantz
- Department of Cardiovascular DiseasesMayo ClinicRochesterMN
- William J von Liebig Center for Transplantation and Clinical RegenerationMayo ClinicRochesterMN
| | - Sudhir S. Kushwaha
- Department of Cardiovascular DiseasesMayo ClinicRochesterMN
- William J von Liebig Center for Transplantation and Clinical RegenerationMayo ClinicRochesterMN
| | - John M. Stulak
- Department of Cardiovascular SurgeryMayo ClinicRochesterMN
| | - Simon Maltais
- Department of Cardiovascular SurgeryMayo ClinicRochesterMN
| | - Atta Behfar
- Department of Cardiovascular DiseasesMayo ClinicRochesterMN
- William J von Liebig Center for Transplantation and Clinical RegenerationMayo ClinicRochesterMN
- VanCleve Cardiac Regenerative Medicine ProgramCenter for Regenerative MedicineMayo ClinicRochesterMN
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Kassi M, Rosenbaum AN, Wiley BM, Behfar A. Novel Use for Intracardiac Echocardiography. JACC Cardiovasc Imaging 2019; 12:363-366. [DOI: 10.1016/j.jcmg.2018.06.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 05/31/2018] [Accepted: 06/22/2018] [Indexed: 01/08/2023]
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Naksuk N, Tan N, Padmanabhan D, Kancharla K, Makkar N, Yogeswaran V, Gaba P, Kaginele P, Riley DC, Sugrue AM, Rosenbaum AN, El-Harasis MA, Asirvatham SJ, Kapa S, McLeod CJ. Right Ventricular Dysfunction and Long-Term Risk of Sudden Cardiac Death in Patients With and Without Severe Left Ventricular Dysfunction. Circ Arrhythm Electrophysiol 2018; 11:e006091. [DOI: 10.1161/circep.117.006091] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [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: 11/29/2017] [Accepted: 03/19/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Niyada Naksuk
- Departments of Cardiovascular Medicine (N.N., D.P., K.K., N.M., P.K., D.C.R., A.M.S., A.N.R., S.J.A., S.K., C.J.M.)
| | | | - Deepak Padmanabhan
- Departments of Cardiovascular Medicine (N.N., D.P., K.K., N.M., P.K., D.C.R., A.M.S., A.N.R., S.J.A., S.K., C.J.M.)
| | - Krishna Kancharla
- Departments of Cardiovascular Medicine (N.N., D.P., K.K., N.M., P.K., D.C.R., A.M.S., A.N.R., S.J.A., S.K., C.J.M.)
- Mayo Clinic, Rochester, MN. Department of Cardiovascular Medicine, University of Pittsburgh Medical Center, PA (K.K.)
| | - Nayani Makkar
- Departments of Cardiovascular Medicine (N.N., D.P., K.K., N.M., P.K., D.C.R., A.M.S., A.N.R., S.J.A., S.K., C.J.M.)
| | | | | | - Pranita Kaginele
- Departments of Cardiovascular Medicine (N.N., D.P., K.K., N.M., P.K., D.C.R., A.M.S., A.N.R., S.J.A., S.K., C.J.M.)
| | - David C. Riley
- Departments of Cardiovascular Medicine (N.N., D.P., K.K., N.M., P.K., D.C.R., A.M.S., A.N.R., S.J.A., S.K., C.J.M.)
| | - Alan M. Sugrue
- Departments of Cardiovascular Medicine (N.N., D.P., K.K., N.M., P.K., D.C.R., A.M.S., A.N.R., S.J.A., S.K., C.J.M.)
| | - Andrew N. Rosenbaum
- Departments of Cardiovascular Medicine (N.N., D.P., K.K., N.M., P.K., D.C.R., A.M.S., A.N.R., S.J.A., S.K., C.J.M.)
| | | | - Samuel J. Asirvatham
- Departments of Cardiovascular Medicine (N.N., D.P., K.K., N.M., P.K., D.C.R., A.M.S., A.N.R., S.J.A., S.K., C.J.M.)
- and Department of Pediatrics and Adolescent Medicine (S.J.A.),
| | - Suraj Kapa
- Departments of Cardiovascular Medicine (N.N., D.P., K.K., N.M., P.K., D.C.R., A.M.S., A.N.R., S.J.A., S.K., C.J.M.)
| | - Christopher J. McLeod
- Departments of Cardiovascular Medicine (N.N., D.P., K.K., N.M., P.K., D.C.R., A.M.S., A.N.R., S.J.A., S.K., C.J.M.)
- Mayo Clinic College of Medicine and Science, Rochester, MN. Mayo Clinic School of Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, FL (C.J.M.)
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Witt CM, Lenz CJ, Shih HH, Ebrille E, Rosenbaum AN, van Zyl M, Aung H, Manocha KK, Deshmukh AJ, Hodge DO, Mulpuru SK, Cha YM, Espinosa RE, Asirvatham SJ, Mcleod CJ. Right ventricular pacemaker lead position is associated with differences in long-term outcomes and complications. J Cardiovasc Electrophysiol 2017; 28:924-930. [PMID: 28543771 DOI: 10.1111/jce.13256] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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: 03/01/2017] [Revised: 04/27/2017] [Accepted: 05/15/2017] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Cardiac pacing from the right ventricular apex is associated with detrimental long-term effects and nonapical pacing locations may be associated with improved outcomes. There is little data regarding complications with nonapical lead positions. The aim of this study was to assess long-term outcomes and lead-related complications associated with differing ventricular lead tip position. METHODS AND RESULTS All adult patients who underwent dual-chamber pacemaker implantation from 2004 to 2014 were included if they had postprocedure chest radiographs amenable to lead position determination. Long-term outcomes and lead-related complication rates were recorded. These were compared at 5 years between: (1) apical and septal leads, (2) apical and nonseptal nonapical (NSNA), and (3) apical and septal with >40% ventricular pacing. We retrospectively evaluated 3,450 patients, which included 238 with a septal position and 733 with NSNA lead positions. Septal lead position was associated with a lower mortality compared to apical leads (24% vs. 31%, P = 0.02). In patients with greater than 40% pacing, septal leads were associated with significantly higher rates of incident atrial fibrillation compared to apical leads (49% vs. 34%, P = 0.04). NSNA positions were associated with a significantly higher rate of lead dislodgement (4% vs. 2%, P = 0.005) and need for revision (8% vs. 5%, P = 0.005). CONCLUSIONS Septal pacemaker lead position is associated with a lower mortality compared to apically placed leads, but a higher incidence of atrial fibrillation with higher percentage ventricular pacing. NSNA lead locations are associated with more complications and should be avoided.
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Affiliation(s)
| | | | | | | | | | | | - Htin Aung
- Department of Cardiovascular Diseases
| | | | | | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
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Naksuk N, Hu T, Krittanawong C, Thongprayoon C, Sharma S, Park JY, Rosenbaum AN, Gaba P, Killu AM, Sugrue AM, Peeraphatdit T, Herasevich V, Bell MR, Brady PA, Kapa S, Asirvatham SJ. Association of Serum Magnesium on Mortality in Patients Admitted to the Intensive Cardiac Care Unit. Am J Med 2017; 130:229.e5-229.e13. [PMID: 27639872 DOI: 10.1016/j.amjmed.2016.08.033] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [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: 07/29/2016] [Revised: 08/16/2016] [Accepted: 08/16/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Although electrolyte disturbances may affect cardiac action potential, little is known about the association between serum magnesium and corrected QT (QTc) interval as well as clinical outcomes. METHODS A consecutive 8498 patients admitted to the Mayo Clinic Hospital-Rochester cardiac care unit (CCU) from January 1, 2004 through December 31, 2013 with 2 or more documented serum magnesium levels, were studied to test the hypothesis that serum magnesium levels are associated with in-hospital mortality, sudden cardiac death, and QTc interval. RESULTS Patients were 67 ± 15 years; 62.2% were male. The primary diagnoses for CCU admissions were acute myocardial infarction (50.7%) and acute decompensated heart failure (42.5%), respectively. Patients with higher magnesium levels were older, more likely male, and had lower glomerular filtration rates. After multivariate analyses adjusted for clinical characteristics including kidney disease and serum potassium, admission serum magnesium levels were not associated with QTc interval or sudden cardiac death. However, the admission magnesium levels ≥2.4 mg/dL were independently associated with an increase in mortality when compared with the reference level (2.0 to <2.2 mg/dL), having an adjusted odds ratio of 1.80 and a 95% confidence interval of 1.25-2.59. The sensitivity analysis examining the association between postadmission magnesium and analysis that excluded patients with kidney failure and those with abnormal serum potassium yielded similar results. CONCLUSION This retrospective study unexpectedly observed no association between serum magnesium levels and QTc interval or sudden cardiac death. However, serum magnesium ≥2.4 mg/dL was an independent predictor of increased hospital morality among CCU patients.
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Affiliation(s)
- Niyada Naksuk
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Tiffany Hu
- Mayo Medical School, Mayo Clinic College of Medicine, Rochester, Minn
| | - Chayakrit Krittanawong
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minn; Department of Medicine, Cleveland Clinic, Ohio; CharlesMedLab, Cleveland, Ohio
| | - Charat Thongprayoon
- Department of Anesthesiology, Mayo Clinic, Rochester, Minn; Department of Internal Medicine, Mary Imogene Bassett Healthcare, Cooperstown, NY
| | - Sunita Sharma
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn; Division of Cardiovascular Diseases, Lahey Hospital and Medical Center, Burlington, Mass
| | - Jae Yoon Park
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Andrew N Rosenbaum
- Division of Cardiovascular Diseases, Lahey Hospital and Medical Center, Burlington, Mass
| | - Prakriti Gaba
- Mayo Medical School, Mayo Clinic College of Medicine, Rochester, Minn
| | - Ammar M Killu
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Alan M Sugrue
- Division of Cardiovascular Diseases, Lahey Hospital and Medical Center, Burlington, Mass
| | - Thoetchai Peeraphatdit
- Division of Internal Medicine, Department of Medicine Education, University of Minnesota Twin Cities, Minneapolis; Division of Gastroenterology, Department of Medicine, Mayo Clinic, Rochester, Minn
| | | | - Malcolm R Bell
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Peter A Brady
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Suraj Kapa
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minn; Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minn.
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Witt CM, Lenz CJ, Shih HH, Ebrille E, Rosenbaum AN, Aung H, van Zyl M, Manocha KK, Deshmukh AJ, Hodge DO, Mulpuru SK, Cha YM, Espinosa RE, Asirvatham SJ, McLeod CJ. Right atrial lead fixation type and lead position are associated with significant variation in complications. J Interv Card Electrophysiol 2016; 47:313-319. [DOI: 10.1007/s10840-016-0181-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 08/26/2016] [Indexed: 11/28/2022]
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Rosenbaum AN, Kremers WK, Schirger JA, Thomas RJ, Squires RW, Allison TG, Daly RC, Kushwaha SS, Edwards BS. Association Between Early Cardiac Rehabilitation and Long-term Survival in Cardiac Transplant Recipients. Mayo Clin Proc 2016; 91:149-56. [PMID: 26848001 DOI: 10.1016/j.mayocp.2015.12.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [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: 09/11/2015] [Accepted: 12/07/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine whether participation in early cardiac rehabilitation (CR) after heart transplant (HTx) affects long-term survival. PATIENTS AND METHODS A retrospective review was conducted in 201 patients who underwent HTx at Mayo Clinic between June 1, 2000, and July 31, 2013. Patients were excluded with multiorgan transplant, no CR data, and follow-up less than 90 days after HTx. Demographic and exercise data at baseline before HTx were collected. Post-HTx exercise capacity, biopsy, CR data, and medications were collected at 1 through 5 and 10 years. RESULTS Overall survival at 1, 5, and 10 years was 98%, 88%, and 82%, respectively; 29 patients died. Number of CR sessions attended in the first 90 days after HTx predicted survival in multivariate regression, controlling for baseline post-HTx 6-minute walk test (6MWT) results and rejection episodes (hazard ratio, 0.90; 95% CI, 0.82-0.97; P=.007). Additional univariate predictors of survival included pre-HTx 6MWT results, weight at HTx, and body mass index and systolic blood pressure at CR enrollment. Pre-HTx 6MWT results, body mass index, and post-HTx were associated with improvement in peak oxygen consumption. CONCLUSION This report demonstrates, for the first time, an association between CR and long-term survival in patients after HTx. Further work should clarify the most beneficial aspects of CR.
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Affiliation(s)
| | - Walter K Kremers
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN; William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - John A Schirger
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN; William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Randal J Thomas
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Ray W Squires
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | - Richard C Daly
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN; William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Sudhir S Kushwaha
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN; William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Brooks S Edwards
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN; William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
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Naksuk N, Thongprayoon C, Park JY, Sharma S, Gaba P, Rosenbaum AN, Peeraphatdit T, Hu TY, Bell MR, Herasevich V, Brady PA, Kapa S, Asirvatham SJ. Editor’s Choice-Clinical impact of delirium and antipsychotic therapy: 10-Year experience from a referral coronary care unit. European Heart Journal: Acute Cardiovascular Care 2015; 6:560-568. [DOI: 10.1177/2048872615592232] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Niyada Naksuk
- Division of Cardiovascular Diseases, Mayo Clinic, USA
| | | | - Jae Y Park
- Division of Cardiovascular Diseases, Mayo Clinic, USA
| | - Sunita Sharma
- Division of Hospital Internal Medicine, Mayo Clinic, USA
| | - Prakriti Gaba
- Mayo Medical School, Mayo Clinic College of Medicine, USA
| | | | | | - Tiffany Y Hu
- Mayo Medical School, Mayo Clinic College of Medicine, USA
| | | | | | - Peter A Brady
- Division of Cardiovascular Diseases, Mayo Clinic, USA
| | - Suraj Kapa
- Division of Cardiovascular Diseases, Mayo Clinic, USA
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Mayo Clinic, USA
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, USA
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Rosenbaum AN, Anavekar NS, Ernste FC, Mankad SV, Le RJ, Manocha KK, Barsness GW. A case of catastrophic antiphospholipid syndrome: first report with advanced cardiac imaging using MRI. Lupus 2015; 24:1338-41. [DOI: 10.1177/0961203315587960] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 04/28/2015] [Indexed: 11/16/2022]
Abstract
This present case pertains to a 48-year-old woman with a history of antiphospholipid syndrome, who presented with progressive fatigue, generalized weakness, and orthopnea acutely. She had a prior diagnosis of antiphospholipid syndrome with recurrent deep vein thromboses (DVTs) and repeated demonstration of lupus anticoagulants. She presented in cardiogenic shock with markedly elevated troponin and global myocardial dysfunction on echocardiography, and cardiac catheterization revealed minimal disease. Cardiac magnetic resonance imaging was performed, which revealed findings of perfusion defects and microvascular obstruction, consistent with the pathophysiology of catastrophic antiphospholipid syndrome (CAPS). Diagnosis was made based on supportive imaging, including head magnetic resonance imaging (MRI) revealing multifocal, acute strokes; microvascular thrombosis in the dermis; and subacute renal infarctions. The patient was anticoagulated with intravenous unfractionated heparin and received high-dose methylprednisolone, plasmapheresis, intravenous immunoglobulin, and one dose each of rituximab and cyclophosphamide. She convalesced with eventual myocardial recovery after a complicated course. The diagnosis of CAPS relies on the presence of (1) antiphospholipid antibodies and (2) involvement of multiple organs in a microangiopathic thrombotic process with a close temporal association. The myocardium is frequently affected, and heart failure, either as the presenting symptom or cause of death, is common. Despite echocardiographic evidence of myocardial dysfunction in such patients, MRIs of CAPS have not previously been reported. This case highlights the utility in assessing the involvement of the myocardium by the microangiopathic process with MRI. Because the diagnosis of CAPS requires involvement in multiple organ systems, cardiac MRI is likely an underused tool that not only reaffirms the pathophysiology of CAPS, but could also clue clinicians in to the possibility of a diffuse thrombotic process.
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Affiliation(s)
- A N Rosenbaum
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - N S Anavekar
- Department of Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - F C Ernste
- Department of Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - S V Mankad
- Department of Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - R J Le
- Department of Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - K K Manocha
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - G W Barsness
- Department of Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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Koene RJ, Win S, Naksuk N, Adatya SN, Rosenbaum AN, John R, Eckman PM. HAS-BLED and CHA2DS2-VASc Scores as Predictors of Bleeding and Thrombotic Risk After Continuous-Flow Ventricular Assist Device Implantation. J Card Fail 2014; 20:800-7. [DOI: 10.1016/j.cardfail.2014.08.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 08/16/2014] [Accepted: 08/19/2014] [Indexed: 01/12/2023]
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