Publications (27) View all
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Article: Interleukin receptor family member ST2 concentrations in patients following heart transplantation.
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ABSTRACT: Abstract Objective: To evaluate soluble (s) ST2 as a biomarker of rejection, allograft vasculopathy and mortality after orthotopic heart transplantation (OHT). Methods: sST2 concentrations were measured in 241 patients following OHT. Results: Elevated sST2 was associated with cellular rejection (CR) ≥1R, with highest rates of CR in the 4th sST2 quartile (p = 0.003). No significant association between sST2 and antibody-mediated rejection or allograft vasculopathy was found. sST2 ≥30 ng/mL independently predicted death over 7-year follow-up (HR = 2.01; 95% CI 1.15-3.51; p = 0.01). Conclusion: Concentrations of sST2 are associated with the presence of CR and predict long-term mortality following OHT.Biomarkers 04/2013; · 2.21 Impact Factor -
Article: Magnitude and Time Course of Changes Induced by Continuous-Flow Left Ventricular Assist Device Unloading in Chronic Heart Failure: Insights into Cardiac Recovery.
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ABSTRACT: OBJECTIVE: To prospectively investigate the longitudinal effects of continuous-flow left ventricular assist device (LVAD) unloading on myocardial structure and systolic and diastolic function. BACKGROUND: The magnitude, timeline and sustainability of changes induced by continuous-flow LVAD on the structure and function of the failing human heart are unknown. METHODS: Eighty consecutive patients with clinical characteristics consistent with chronic heart failure requiring implantation of a continuous-flow LVAD were prospectively enrolled. Serial echocardiograms (1, 2, 3, 4, 6, 9 and 12 months) and right heart catheterizations were performed after LVAD implant. Cardiac recovery was assessed on the basis of improvement in systolic and diastolic function indices on echocardiography that were sustained during LVAD turn-down studies. RESULTS: After 6 months of LVAD unloading, 34% of patients had a relative LVEF increase above 50% and 19% of patients, both ischemic and nonischemic, achieved an LVEF≥40%. LV systolic function improved as early as 30 days, the greatest degree of improvement was achieved by 6 months of mechanical unloading and persisted over the 1- year follow up. LV diastolic function parameters also improved as early as 30 days post LVAD unloading and this improvement persisted over time. LV end-diastolic and end-systolic volumes decreased as early as 30 days post LVAD unloading (113 vs. 77ml/m2, p<0.01 and 92 vs. 60ml/m2, p<0.01, respectively). LV mass decreased as early as 30 days post LVAD unloading (114 vs. 95g/m(2), p<0.05) and continued to do so over the 1-year follow-up but did not reach values below the normal reference range suggesting no atrophic remodeling after prolonged LVAD unloading. CONCLUSION: Continuous-flow LVAD unloading induced in a subset of patients, both ischemic and nonischemic, early improvement in myocardial structure and systolic and diastolic function that was largely completed within 6 months, with no evidence of subsequent regression.Journal of the American College of Cardiology 03/2013; · 14.16 Impact Factor -
Article: Electromagnetic Interference of Automatic Implantable Cardioverter Defibrillator and HeartWare Left Ventricular Assist Device.
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ABSTRACT: The use of continuous-flow left ventricular assist devices (LVAD) have markedly improved outcomes in patients with advanced heart failure (HF). The HeartWare LVAD is a miniaturized centrifugal pump implanted within the pericardial space. Implantable cardioverter-defibrillators (ICDs) are susceptible to oversensing of extracardiac signals (electromagnetic interference [EMI]). We report two cases of EMI in patients that received a HeartWare LVAD as destination therapy for advanced HF. The patients were 75 and 78 years old, both with severe ischemic dilated cardiomyopathy (ejection fraction < 0.20) and New York Heart Association class 4 heart failure. Both patients had a St. Jude Medical Unify ICD with a 7 Fr dual coil St. Jude Medical Durata ICD lead. In both patients, the lead location was in the right ventricular apex with an inferior orientation. Both patients experienced immediate ICD therapies after LVAD placement, requiring the tachytherapies to be disabled. ICD programming changes to increase sensitivity and the detection windows were ineffective. Both patients underwent ICD system revision. In one patient, the existing lead was moved to an anteroseptal location that stopped the EMI. In the other patient, the ICD system was changed to allow a separate right ventricular sensing lead in an anteroseptal location and a dual coil ICD lead placed in an apical location, a strategy used to obtain an acceptable defibrillation threshold. The patients have had no subsequent EMI detected on clinical and remote monitoring. Patients with a right ventricular apical ICD lead placement that undergo placement of a HeartWare LVAD are susceptible to EMI and inappropriate ICD therapies. These cases suggest the primary mechanism is proximity of the ICD lead to the device and as such relocation to an anteroseptal location can overcome the problem. These data suggest that all patients that receive a HeartWare LVAD with an ICD should have the device carefully checked at maximum LVAD output to determine if EMI may be present. ASAIO Journal 2013;59:136-139. Key Words: left ventricular assist device, electromagnetic interference, improper ICD shocks, end-stage heart failure.ASAIO journal (American Society for Artificial Internal Organs: 1992) 03/2013; 59(2):136-9. · 1.39 Impact Factor -
Article: Morbidity and Mortality in Heart Transplant Candidates Supported with Mechanical Circulatory Support. Is Reappraisal of the Current UNOS Thoracic Organ Allocation Policy Justified?
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ABSTRACT: BACKGROUND: Survival of patients on left ventricular assist devices (LVADs) has improved. We examined the differences in risk of adverse outcomes between LVAD supported and medically managed candidates on the heart transplant waiting list. METHODS AND RESULTS: We analyzed mortality and morbidity in 33,073 heart transplant candidates registered on the United Network for Organ Sharing (UNOS) waiting list between 1999 and 2011. Five groups were selected: patients without LVADs in urgency Status 1A, 1B and 2, patients with pulsatile-flow (PF) and patients with continuous-flow (CF) LVADs. Outcomes in patients requiring biventricular assist devices (BIVADs), total artificial heart (TAH) and temporary VADs were also analyzed. Two eras were defined based on the approval date of the first CF-LVAD for bridge-to-transplant in the US (2008). Mortality was lower in the current compared with the first era - 2.1% vs. 2.9%/month, p<0.0001. In the first era, mortality of PF-LVAD patients was higher than in Status 2 (HR 2.15, p<0.0001) and similar to Status 1B patients (HR 1.04, p=0.61). In the current era, patients with CF-LVADs had similar mortality compared to Status 2 (HR 0.80, P=0.12) and lower mortality compared with Status 1A and 1B patients (HR 0.24 and 0.47, p<0.0001 for both comparisons). However, status upgrade for LVAD-related complications occurred frequently (28%) and increased the mortality risk (HR 1.75, p=0.001). Mortality was highest in patients with BIVADs (HR 5.00, p<0.0001) and temporary VADs (HR 7.72, p<0.0001). CONCLUSIONS: Mortality and morbidity on the heart transplant waiting list have decreased. Candidates supported with contemporary CF-LVADs have favorable waiting list outcomes; however, these worsen significantly once a serious LVAD-related complication occurs. Transplant candidates requiring temporary and biventricular support have the highest risk of adverse outcomes. These results may help to guide optimal allocation of donor hearts.Circulation 12/2012; · 14.74 Impact Factor -
Article: Biopsy-diagnosed antibody-mediated rejection based on the proposed International Society for Heart and Lung Transplantation working formulation is associated with adverse cardiovascular outcomes after pediatric heart transplant.
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ABSTRACT: There is greater awareness of the pathologic features and clinical implications of antibody-mediated rejection (AMR) after heart transplantation (HT). Yet, compared with adults, the lack of routine surveillance for AMR has limited the growth of evidence in the pediatric population. Herein, we compared outcomes of pediatric HT recipients with and without AMR. All recipients ≤18 years of age with at least 1 endomyocardial biopsy (EMB) between 1988 and 2009 were included in this study. Assessment for AMR was routine. AMR severity was assigned retrospectively using the proposed 2011 ISHLT grading schema for pathologic AMR (pAMR). Outcome comparisons were made between patients with histologic and immunopathologic evidence for AMR (pAMR 2), those with severe AMR (pAMR 3), and those without evidence of AMR (pAMR 0) or without both histologic and immunopathologic findings (pAMR 1). Among 1,406 EMBs, pAMR 2 or higher was present in 258 (18%), occurring in 45 of 76 (59%) patients. Of the 17 episodes of pAMR 3 in 9 patients, 6 (35%) were sub-clinical. Mortality was not different between groups. Patients with at least 1 pAMR 3 episode had lower freedom from cardiovascular (CV) mortality or cardiac allograft vasculopathy within 5 years of HT than those without pAMR 3 (45% vs 91%, p < 0.001). Biopsy findings of AMR (pAMR 2 or higher) are common after pediatric HT. Like cellular rejection, biopsy grading of AMR seems important to delineate those at risk of adverse events. Our results suggest that pAMR 3 is associated with worse CV outcomes. Widespread surveillance for pAMR with a uniform grading system is an important next step to further validate these findings in the pediatric HT population.The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 05/2012; 31(7):686-93. · 3.54 Impact Factor
