-
[show abstract]
[hide abstract]
ABSTRACT: OBJECTIVES: To determine if nesiritide increases diuresis in congestive heart failure (CHF) patients. BACKGROUND: In ASCEND-HF, 7141 patients hospitalized with acute decompensated heart failure (ADHF) were randomized to receive nesiritide or placebo for 24-168 hours, in addition to standard care. There were minimal effects of nesiritide on survival, future hospitalizations, and symptoms. However, whether or not nesiritide increases diuresis in ADHF patients is unknown. METHODS: Urine output was measured in 5864 subjects; of these, 5320 received loop diuretics and had dose data recorded. Loop diuretics other than furosemide were converted to "furosemide equivalent doses." A total of 4881 patients had complete data. We used logistic regression models to identify the impact of nesiritide on urine output and the factors associated with high urine output. RESULTS: Median (25(th), 75(th) %) 24 hour urine output was 2280 (1550, 3280) ml with nesiritide and 2200 (1550, 3200) ml with placebo (p=NS). Loop diuretic dose (furosemide equivalent) was 80 (40, 140) mg with both nesiritide and placebo. Diuretic dose was a strong predictor of urine output. Other independent predictors included: male sex, greater body mass index, higher diastolic blood pressure, elevated jugular venous pressure, recent weight gain, and lower blood urea nitrogen (BUN). The addition of nesiritide did not change urine output. None of the interaction terms between nesiritide and predictors affected the urine output prediction. CONCLUSIONS: Nesiritide did not increase urine output in patients with ADHF. Higher diuretic dose was a strong predictor of higher urine output, but neurohormonal activation (as evidenced by BUN concentration) and lower blood pressure limited diuresis.
Journal of the American College of Cardiology 06/2013; · 14.16 Impact Factor
-
Michael M Givertz,
John R Teerlink,
Nancy M Albert,
Cheryl A Westlake Canary,
Sean P Collins,
Monica Colvin-Adams,
Justin A Ezekowitz,
James C Fang,
Adrian F Hernandez,
Stuart D Katz, [......],
Javed Butler,
Peter E Carson,
John P Dimarco,
Ray E Hershberger,
Joseph G Rogers,
John A Spertus,
William G Stevenson,
Nancy K Sweitzer,
W H Wilson Tang, Randall C Starling
[show abstract]
[hide abstract]
ABSTRACT: Acute decompensated heart failure (ADHF) is a complex clinical event associated with excess morbidity and mortality. Managing ADHF patients is challenging because of the lack of effective treatments that both reduce symptoms and improve clinical outcomes. Existing guideline recommendations are largely based on expert opinion, but several recently published trials have yielded important data to inform both current clinical practice and future research directions. New insight has been gained regarding volume management, including dosing strategies for intravenous loop diuretics and the role of ultrafiltration in patients with heart failure and renal dysfunction. Although the largest ADHF trial to date (ASCEND-HF, using nesiritide) was neutral, promising results with other investigational agents have been reported. If these findings are confirmed in phase III trials, novel compounds, such as relaxin, omecamtiv mecarbil, and ularitide, among others, may become therapeutic options. Translation of research findings into quality clinical care can not be overemphasized. Although many gaps in knowledge exist, ongoing studies will address issues around delivery of evidence-based care to achieve the goal of improving the health status and clinical outcomes of patients with ADHF.
Journal of cardiac failure 06/2013; 19(6):371-89. · 3.25 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The development of ventricular assist devices (VADs) over the past 5 decades as therapy for advanced heart failure (HF) has been extraordinary. Since the original VAD design by Michael DeBakey in the early 1960s, numerous devices for mechanical circulatory support have been engineered, assessed in preclinical studies, applied to human patients in large multicenter clinical trials, and now, select devices are Food and Drug Administration-approved therapy for advanced HF patients. This review highlights select examples of durable VADs from the engineering aspect of design and conception to experimental studies and clinical application underscoring the remarkable progression of such technology to now becoming the standard of care for many advanced HF patients.
Cardiology 04/2013; 125(1):1-12. · 1.71 Impact Factor
-
Journal of the American College of Cardiology 03/2013; · 14.16 Impact Factor
-
Journal of the American College of Cardiology 01/2013; 61(4):484. · 14.16 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: AIMS: 'Worsening renal function' (WRF) and 'improvement in renal function' (IRF) monitored by changes in serum creatinine are frequently encountered during treatment of acute decompensated heart failure (ADHF). We sought to establish the important haemodynamic determinants of alterations in serum creatinine. METHODS AND RESULTS: We reviewed data from 443 patients treated for ADHF with haemodynamic guidance in a single centre. WRF and IRF were defined as a 25% increase or decrease in estimated glomerular filtration rate (eGFR) from time of admission to pulmonary artery catheter removal, respectively. Of the 443 patients, 46 (10%) experienced WRF and 127 (29%) had IRF. Baseline eGFR was lower in patients with IRF when compared with stable patients or those with WRF (45 ± 25 vs. 63 ± 30 vs. 68 ± 27 mL/min/m(2), respectively, P < 0.0001). In contrast, the relative decrease in mean blood pressure (BP) was more pronounced in patients with WRF when compared with stable patients or those with IRF (15 ± 15 vs. 9 ± 17 vs. 4 ± 15%, respectively, P = 0.003). With larger decreases in mean BP, there was greater likelihood of experiencing WRF (P = 0.04) but less likelihood of experiencing IRF (P = 0.01). In contrast, the degree of changes in right atrial pressure or cardiac index did not affect the propensity for developing WRF or IRF. There was no difference in adverse clinical outcomes (death, heart transplantation, LV assist device implantation, or readmission) between the three groups (P = 0.56). CONCLUSION: Blood pressure decrease, rather than alterations in cardiac output or central venous pressure, were associated with changes in serum creatinine during treatment of ADHF.
European Journal of Heart Failure 01/2013; · 4.90 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The recent success of continuous-flow circulatory support devices has led to the growing acceptance of these devices as a viable therapeutic option for end-stage heart failure patients who are not responsive to current pharmacologic and electrophysiologic therapies. This article defines and clarifies the major classification of these pumps as axial or centrifugal continuous-flow devices by discussing the difference in their inherent mechanics and describing how these features translate clinically to pump selection and patient management issues. Axial vs centrifugal pump and bearing design, theory of operation, hydrodynamic performance, and current vs flow relationships are discussed. A review of axial vs centrifugal physiology, pre-load and after-load sensitivity, flow pulsatility, and issues related to automatic physiologic control and suction prevention algorithms is offered. Reliability and biocompatibility of the two types of pumps are reviewed from the perspectives of mechanical wear, implant life, hemolysis, and pump deposition. Finally, a glimpse into the future of continuous-flow technologies is presented.
The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 01/2013; 32(1):1-11. · 3.54 Impact Factor
-
Michael A Acker,
Francis D Pagani,
Wendy Gattis Stough,
Douglas L Mann,
Mariell Jessup,
Robert Kormos,
Mark S Slaughter,
Timothy Baldwin,
Lynne Stevenson,
Keith D Aaronson, [......],
Joseph Rogers,
Jeffrey Teuteberg, Randall C Starling,
Bartley Griffith,
Steven Boyce,
Stephen Westaby,
Elizabeth Blume,
Peter Wearden,
Robert Higgins,
Michael Mack
-
[show abstract]
[hide abstract]
ABSTRACT: In this report, we present a successful reuse of a transplanted heart under complex clinical conditions. Our patient was the second recipient, a 63-year-old man with end-stage heart failure due to amyloid-induced cardiomyopathy. After an uneventful postoperative course, he was diagnosed with acute myelogenous leukemia 6 months after transplantation and died 10 months after transplantation. This outcome was determined by a malignancy in an immunosuppressed patient. Reuse of a transplanted heart in carefully selected patients is a possible alternative in an era of donor organ shortage.
The Annals of thoracic surgery 12/2012; 94(6):e143-4. · 3.74 Impact Factor
-
Michael A Acker,
Francis D Pagani,
Wendy Gattis Stough,
Douglas L Mann,
Mariell Jessup,
Robert Kormos,
Mark S Slaughter,
Timothy Baldwin,
Lynne Stevenson,
Keith D Aaronson, [......],
Joseph Rogers,
Jeffrey Teuteberg, Randall C Starling,
Bartley Griffith,
Steven Boyce,
Stephen Westaby,
Elizabeth Blume,
Peter Wearden,
Robert Higgins,
Michael Mack
[show abstract]
[hide abstract]
ABSTRACT: The incorporation of complex medical device technologies into clinical practice is governed by critical oversight of the United States Food and Drug Administration. This regulatory process requires a judicious balance between assuring safety and efficacy, while providing efficient review to facilitate access to innovative therapies. Recent contrasting views of the regulatory process have emphasized the difficulties in obtaining an optimal balance. Mechanical circulatory support has evolved to become an important therapy for patients who have advanced heart failure with the advent of more durable, implantable ventricular assist devices. The regulatory oversight of these new technologies has been difficult owing to the complexities of these devices, associated adverse event profile, and severity of illness of the intended patient population. Maintaining a regulatory environment to foster efficient introduction of safe and effective technologies is critical to the success of ventricular assist device therapy and the health of patients with advanced heart failure. Physicians representing key surgical and cardiology societies, and representatives from the Food and Drug Administration, National Heart Lung, and Blood Institute, Centers for Medicare and Medicaid Services, Inter-agency Registry of Mechanically Assisted Circulatory Support, and industry partners gathered to discuss relevant issues regarding the current regulatory environment assessing ventricular assist devices. The goal of the meeting was to explore innovative ways to foster the introduction of technologically advanced, safe, and effective ventricular assist devices. The following summary reflects opinions and conclusions endorsed by The Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, Heart Failure Society of America, International Society for Heart and Lung Transplantation, and Interagency Registry of Mechanically Assisted Circulatory Support.
The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 12/2012; 31(12):1241-52. · 3.54 Impact Factor
-
Michael A Acker,
Francis D Pagani,
Wendy Gattis Stough,
Douglas L Mann,
Mariell Jessup,
Robert Kormos,
Mark S Slaughter,
Timothy Baldwin,
Lynne Stevenson,
Keith D Aaronson, [......],
Joseph Rogers,
Jeffrey Teuteberg, Randall C Starling,
Bartley Griffith,
Steven Boyce,
Stephen Westaby,
Elizabeth Blume,
Peter Wearden,
Robert Higgins,
Michael Mack
[show abstract]
[hide abstract]
ABSTRACT: The incorporation of complex medical device technologies into clinical practice is governed by critical oversight of the US Food and Drug Administration. This regulatory process requires a judicious balance between assuring safety and efficacy, while providing efficient review to facilitate access to innovative therapies. Recent contrasting views of the regulatory process have emphasized the difficulties in obtaining an optimal balance. Mechanical circulatory support has evolved to become an important therapy for patients who have advanced heart failure with the advent of more durable, implantable ventricular assist devices. The regulatory oversight of these new technologies has been difficult owing to the complexities of these devices, associated adverse event profile, and severity of illness of the intended patient population. Maintaining a regulatory environment to foster efficient introduction of safe and effective technologies is critical to the success of ventricular assist device therapy and the health of patients with advanced heart failure. Physicians representing key surgical and cardiology societies, and representatives from the Food and Drug Administration, National Heart, Lung, and Blood Institute, Centers for Medicare and Medicaid Services, Interagency Registry of Mechanically Assisted Circulatory Support, and industry partners gathered to discuss relevant issues regarding the current regulatory environment assessing ventricular assist devices. The goal of the meeting was to explore innovative ways to foster the introduction of technologically advanced, safe, and effective ventricular assist devices. The following summary reflects opinions and conclusions endorsed by The Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, Heart Failure Society of America, International Society for Heart and Lung Transplantation, and Interagency Registry of Mechanically Assisted Circulatory Support.
Circulation Heart Failure 11/2012; · 6.29 Impact Factor
-
Michael A Acker,
Francis D Pagani,
Wendy Gattis Stough,
Douglas L Mann,
Mariell Jessup,
Robert Kormos,
Mark S Slaughter,
Timothy Baldwin,
Lynne Stevenson,
Keith D Aaronson, [......],
Joseph Rogers,
Jeffrey Teuteberg, Randall C Starling,
Bartley Griffith,
Steven Boyce,
Stephen Westaby,
Elizabeth Blume,
Peter Wearden,
Robert Higgins,
Michael Mack
[show abstract]
[hide abstract]
ABSTRACT: The incorporation of complex medical device technologies into clinical practice is governed by critical oversight of the US Food and Drug Administration. This regulatory process requires a judicious balance between assuring safety and efficacy, while providing efficient review to facilitate access to innovative therapies. Recent contrasting views of the regulatory process have emphasized the difficulties in obtaining an optimal balance. Mechanical circulatory support has evolved to become an important therapy for patients with advanced heart failure with the advent of more durable, implantable ventricular assist devices. The regulatory oversight of these new technologies has been difficult owing to the complexities of these devices, associated adverse event profile, and severity of illness of the intended patient population. Maintaining a regulatory environment to foster efficient introduction of safe and effective technologies is critical to the success of ventricular assist device therapy and the health of patients with advanced heart failure. Physicians representing key surgical and cardiology societies, and representatives from the Food and Drug Administration, National Heart, Lung, and Blood Institute, Centers for Medicare and Medicaid Services, Interagency Registry of Mechanically Assisted Circulatory Support, and industry partners gathered to discuss relevant issues regarding the current regulatory environment assessing ventricular assist devices. The goal of the meeting was to explore innovative ways to foster the introduction of technologically advanced, safe, and effective ventricular assist devices. The following summary reflects opinions and conclusions endorsed by The Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, Heart Failure Society of America, International Society for Heart and Lung Transplantation, and the Interagency Registry of Mechanically Assisted Circulatory Support.
Circulation Heart Failure 11/2012; · 6.29 Impact Factor
-
Michael A Acker,
Francis D Pagani,
Wendy Gattis Stough,
Douglas L Mann,
Mariell Jessup,
Robert Kormos,
Mark S Slaughter,
Timothy Baldwin,
Lynne Stevenson,
Keith D Aaronson, [......],
Joseph Rogers,
Jeffrey Teuteberg, Randall C Starling,
Bartley Griffith,
Steven Boyce,
Stephen Westaby,
Elizabeth Blume,
Peter Wearden,
Robert Higgins,
Michael Mack
[show abstract]
[hide abstract]
ABSTRACT: The incorporation of complex medical device technologies into clinical practice is governed by critical oversight of the US Food and Drug Administration. This regulatory process requires a judicious balance between assuring safety and efficacy, while providing efficient review to facilitate access to innovative therapies. Recent contrasting views of the regulatory process have emphasized the difficulties in obtaining an optimal balance. Mechanical circulatory support has evolved to become an important therapy for patients with advanced heart failure with the advent of more durable, implantable ventricular assist devices. The regulatory oversight of these new technologies has been difficult owing to the complexities of these devices, associated adverse event profile, and severity of illness of the intended patient population. Maintaining a regulatory environment to foster efficient introduction of safe and effective technologies is critical to the success of ventricular assist device therapy and the health of patients with advanced heart failure. Physicians representing key surgical and cardiology societies, and representatives from the Food and Drug Administration, National Heart Lung, and Blood Institute, Centers for Medicare and Medicaid Services, Interagency Registry of Mechanically Assisted Circulatory Support, and industry partners gathered to discuss relevant issues regarding the current regulatory environment assessing ventricular assist devices. The goal of the meeting was to explore innovative ways to foster the introduction of technologically advanced, safe, and effective ventricular assist devices. The following summary reflects opinions and conclusions endorsed by The Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, Heart Failure Society of America, International Society of Heart and Lung Transplantation, and the Interagency Registry of Mechanically Assisted Circulatory Support.
The Annals of thoracic surgery 11/2012; · 3.74 Impact Factor
-
Michael A Acker,
Francis D Pagani,
Wendy Gattis Stough,
Douglas L Mann,
Mariell Jessup,
Robert Kormos,
Mark S Slaughter,
Timothy Baldwin,
Lynne Stevenson,
Keith D Aaronson, [......],
Joseph Rogers,
Jeffrey Teuteberg, Randall C Starling,
Bartley Griffith,
Steven Boyce,
Stephen Westaby,
Elizabeth Blume,
Peter Wearden,
Robert Higgins,
Michael Mack
[show abstract]
[hide abstract]
ABSTRACT: The incorporation of complex medical device technologies into clinical practice is governed by critical oversight of the US Food and Drug Administration. This regulatory process requires a judicious balance between assuring safety and efficacy, while providing efficient review to facilitate access to innovative therapies. Recent contrasting views of the regulatory process have emphasized the difficulties in obtaining an optimal balance. Mechanical circulatory support has evolved to become an important therapy for patients who have advanced heart failure with the advent of more durable, implantable ventricular assist devices. The regulatory oversight of these new technologies has been difficult owing to the complexities of these devices, associated adverse event profile, and severity of illness of the intended patient population. Maintaining a regulatory environment to foster efficient introduction of safe and effective technologies is critical to the success of ventricular assist device therapy and the health of patients with advanced heart failure. Physicians representing key surgical and cardiology societies, and representatives from the Food and Drug Administration, National Heart Lung, and Blood Institute, Centers for Medicare and Medicaid Services, Interagency Registry of Mechanically Assisted Circulatory Support, and industry partners gathered to discuss relevant issues regarding the current regulatory environment assessing ventricular assist devices. The goal of the meeting was to explore innovative ways to foster the introduction of technologically advanced, safe, and effective ventricular assist devices. The following summary reflects opinions and conclusions endorsed by The Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, Heart Failure Society of America, International Society of Heart and Lung Transplantation, and Interagency Registry of Mechanically Assisted Circulatory Support.
The Annals of thoracic surgery 11/2012; · 3.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: -RV dysfunction frequently occurs and independently prognosticates in left-sided HF. It is not clear which right ventricular (RV) afterload measure has the greatest impact on RV function and prognosis. We examined the determinants, prognostic role and response to treatment of pulmonary arterial capacitance (PAC, ratio of stroke volume over pulmonary pulse pressure), in relation to pulmonary vascular resistance (PVR) in heart failure (HF). METHODS AND RESULTS: -We reviewed 724 consecutive patients with HF who underwent right heart catheterization between 2000 and 2005. Changes in PAC were explored in an independent cohort of 75 subjects treated for acute decompensated HF. PAC showed a strong inverse relation with PVR (r=-0.64) and wedge pressure (r=-0.73), and provides stronger prediction of significant RV failure than PVR (AUC ROC 0.74 vs 0.67 respectively, p = 0.003). During a mean follow-up of 3.2±2.2 years, both lower PAC (p<0.0001) and higher PVR (p<0.0001) portend more adverse clinical events (all-cause mortality and cardiac transplantation). In multivariate analysis, PAC (but not PVR) remains an independent predictor (Hazard ratio =0.92 [95% confidence interval: 0.84-1.0, p=0.037]). Treatment of HF resulted in a decrease in PVR (270±165 to 211±88 dynes·sec·cm(-5), p=0.002), a larger increase in PAC (1.65±0.64 to 2.61±1.42 ml/mmHg, p<0.0001), leading to an increase in pulmonary arterial time constant (PVR x PAC) (0.29±0.12 to 0.37±0.15 sec, p<0.0001). CONCLUSIONS: -PAC bundles the effects of PVR and left sided filling pressures on RV afterload, explaining its strong relation with RV dysfunction, poor long-term prognosis, and response to therapy.
Circulation Heart Failure 10/2012; · 6.29 Impact Factor
-
John P Boehmer, Randall C Starling,
Leslie T Cooper,
Guillermo Torre-Amione,
Ilan Wittstein,
G William Dec,
David W Markham,
Mark J Zucker,
John Gorcsan,
Charles McTiernan,
Kevin Kip,
Dennis M McNamara
[show abstract]
[hide abstract]
ABSTRACT: Left ventricular assist device (LVAD) support as bridge to recovery (BTR) is uncommon for subjects with chronic heart failure. Myocardial recovery is more evident in recent onset nonischemic cardiomyopathy (ROCM); however, the prevalence of BTR in this subset has not been addressed.
We examined the use of LVAD support for subjects with ROCM in the Intervention in Myocarditis and Acute Cardiomyopathy 2 (IMAC2) study. The overall cohort (n = 373) was 38% female, 21% black, with a mean age of 45 ± 14 years. LVAD support was used in 3.8% (n = 14, 43% female, age 32 ± 10). Of LVAD subjects, 57% (8/14) were BTR, including 73% (8/11) of subjects with symptoms ≤4 months at the time of support. Left ventricular end-diastolic diameter (LVEDD) was smaller in BTR than nonrecovered (NR) subjects (P = .04). Myocardial inflammation was more common in BTR (75% versus 0%, P = .005), whereas fibrosis was less evident (25% versus 100%, P = .005). Of BTR subjects, 7/8 (87.5%) were alive and free of transplant with median follow-up of 19 months.
In a multicenter registry of ROCM, BTR was common and occurred in the majority of subjects requiring LVAD support. Histology and LVEDD may assist in predicting potential for BTR in ROCM.
Journal of cardiac failure 10/2012; 18(10):755-61. · 3.25 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: OBJECTIVES: The purpose of this study was to examine the clinical outcomes of using slow continuous ultrafiltration (SCUF) in patients with acute decompensated heart failure (HF) refractory to intensive medical therapy. BACKGROUND: Several studies have demonstrated the clinical usefulness of early SCUF in patients with acute decompensated HF to improve fluid overload and hemodynamics. METHODS: We reviewed clinical data from 63 consecutive adult patients with acute decompensated HF admitted to the Heart Failure Intensive Care Unit from 2004 through 2009 who required SCUF because of congestion refractory to hemodynamically guided intensive medical therapy. RESULTS: The mean creatinine level was 1.9 ± 0.8 mg/dl on admission and 2.2 ± 0.9 mg/dl at SCUF initiation. After 48 hours of SCUF, there were significant improvements in hemodynamic variables (mean pulmonary arterial pressure: 40 ± 12 mm Hg vs. 33 ± 8 mm Hg, p = 0.002, central venous pressure: 20 ± 6 mm Hg vs. 16 ± 8 mm Hg, p = 0.007, mean pulmonary wedge pressure: 27 ± 8 mm Hg vs. 20 ± 7 mm Hg, p = 0.02, Fick cardiac index: 2.2 l/min/m(2) [interquartile range: 1.87 to 2.77 l/min/m(2)] vs. 2.6 l/min/m(2) [interquartile range: 2.2 to 2.9 l/min/m(2)], p = 0.0008), and weight loss (102 ± 25 kg vs. 99 ± 23 kg, p < 0.0001). However, there were no significant improvements in serum creatinine levels (2.2 ± 0.9 mg/dl vs. 2.4 ± 1 mg/dl, p = 0.12) and blood urea nitrogen (60 ± 30 mg/dl vs. 60 ± 28 mg/dl, p = 0.97). Fifty-nine percent required conversion to continuous hemodialysis during their hospital course, and 14% were dependent on dialysis at hospital discharge. Thirty percent died during hospitalization, and 6 patients were discharged to hospice care. CONCLUSIONS: In our single-center experience, SCUF after admission for acute decompensated HF refractory to standard medical therapy was associated with high incidence of subsequent transition to renal replacement therapy and high in-hospital mortality, despite significant improvement in hemodynamics.
Journal of the American College of Cardiology 09/2012; · 14.16 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The value of assessment of viability as a predictor of surgical revascularization benefit in ischemic cardiomyopathy has recently been questioned in a large trial. We sought to determine whether the contribution of viability as myocardial scar burden (SB) to predict revascularization outcomes could be modulated by end-systolic volume index (ESVi).
Delayed hyperenhancement-MRI was obtained in 450 patients with ≥70% stenosis in ≥1 epicardial coronary artery (75% men; median age, 62.8±10.7 years; mean left ventricular ejection fraction, 23±9%; mean ESVi, 115±50 mL) from 2002 to 2006. SB was quantified as scar percentage (infarcted mass/total left ventricular mass). Subsequent surgical revascularization was performed in 245 (54%) patients and subsequent percutaneous coronary interventions were performed in 28 (6%) patients. A propensity score was developed for revascularization. Cox proportional hazards models of all-cause mortality were used for risk adjustment. Over a mean follow-up of 5.8±2.7 years, 186 (41%) deaths occurred. After adjusting for prior revascularization, sex, diabetes, age, use of cardiac resynchronization therapy, implantable cardioverter defibrillator, mitral regurgitation, and mitral valve procedures; an interaction between scar percentage and ESVi (P=0.016) and an interaction between post-MRI revascularization and ESVi (P=0.0017) were independently associated with mortality. ESVi demonstrated a significant interaction with revascularization and female sex, such that enhanced survival was associated with ESVi. ESVi also showed an interaction with SB; better survival was associated with lower volumes and less scar.
ESVi and SB provide independent, incremental prognostic value in patients with severe ischemic cardiomyopathy. The risk associated with SB should not be assessed in isolation.
Circulation 09/2012; 126(11 Suppl 1):S3-8. · 14.74 Impact Factor
-
Richard Sheppard,
Paul J Mather,
Jeffrey D Alexis, Randall C Starling,
John P Boehmer,
Vinay Thohan,
Daniel F Pauly,
David W Markham,
Mark Zucker,
Kevin E Kip,
Dennis M McNamara
[show abstract]
[hide abstract]
ABSTRACT: Given the potential for recovery in recent onset nonischemic cardiomyopathy (ROCM), the timing and need for implantable cardioverter-defibrillator (ICDs) remains controversial. We examined the utilization of ICDs and the impact on survival for subjects with ROCM.
An National Heart, Lung, and Blood Institute sponsored registry enrolled 373 subjects with ROCM, all with a left ventricular ejection fraction (LVEF) ≤0.40 and ≤6 months of symptoms. The mean age was 45 ± 14 years, 38% were female, 21% black, 75% New York Heart Association II/III, and the mean LVEF was 0.24 ± 0.08. Survival was comparable for subjects with an ICD within 1 month of entry (n = 43, 1/2/3 year % survival = 97/97/92) and those with no ICD at 1 month (n = 330, % survival = 98/97/95, P = .30) and between those with and without an ICD at 6 months (ICD, n = 73, 1/2/3 year % survival = 98/98/95; no ICD, n = 300, % survival = 98/96/95, P = .95). There were only 6 sudden cardiac deaths (SCD) noted (% survival free from SCD = 99/98/97) and these occurred in 1.9% of subjects without ICD and 0.9% of those with a device (P = .50).
In a multicenter cohort of ROCM the risk of SCD was low at 1% per year. Early ICD placement did not impact survival and can be deferred while assessing potential for myocardial recovery.
Journal of cardiac failure 09/2012; 18(9):675-81. · 3.25 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This study sought to determine the utility of quantitation of right ventricular (RV) function in predicting RV failure in patients undergoing left ventricular assist device (LVAD) implantation.
Clinical evaluation alone seems insufficient for predicting RV failure, an important cause of morbidity and mortality after LVAD implantation.
Clinical, hemodynamic, and echocardiographic data were collected on 117 patients undergoing LVAD implantation. Standard pre-procedural echocardiographic RV measurements were supplemented by velocity vector imaging of RV free wall longitudinal strain. RV failure was defined as the need for placement of an RV assist device, or the use of inotropic agents for >14 days. Receiver operating characteristic curves were derived, with resampling to generate valid estimates of prediction accuracy. A net reclassification index was calculated for comparison of risk scores.
RV failure occurred in 47 of 117 patients (40%). There was a significant difference in peak strain between patients with and without RV failure (-9.0% vs. -12.2%; p < 0.01). A peak strain cutoff of -9.6% predicted RV failure with 76% specificity and 68% sensitivity. In a multivariate logistic regression analysis including variables from the established Michigan RV risk score, peak strain remained an independent predictor of RV failure. RV strain was incremental to the Michigan risk score as a predictor of RV failure (area under the receiver operating characteristic curve: 0.77 vs. 0.66; p < 0.01). The net reclassification index with strain was +10.4%.
Reduced RV free wall peak longitudinal strain was associated with an increased risk for RV failure among patients undergoing LVAD implantation.
Journal of the American College of Cardiology 08/2012; 60(6):521-8. · 14.16 Impact Factor
