Effectiveness and Safety of the Impella 5.0 as a Bridge to Cardiac Transplantation or Durable Left Ventricular Assist Device

Many patients with end-stage heart failure require mechanical circulatory support as a temporizing measure to enable multidisciplinary assessment for the most suitable therapeutic strategy. Impella 5.0 can be used as a bridge to decision to evaluate patients for potential recovery or bridge to next therapy (bridge to heart transplantation [BTHT] or bridge to durable left ventricular assist device or VAD [BLVAD]. Our goal was to examine single-center outcomes with the Impella 5.0 device as a bridge to next therapy (BTHT or BTLVAD). Forty patients underwent Impella 5.0 support from December 2009 to December 2015 with the intent of BTHT (n = 20) or BTLVAD (n = 20). The primary end point was survival to next therapy. Secondary end points included hemodynamic assessments and in-hospital/30-day complications. All patients were inotrope-dependent, with severely depressed left ventricular ejection fraction (12%) and renal insufficiency (creatinine 2.0 mg/dl). Most were Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) 2 (66%) with biventricular failure (65%). Thirty patients (75%) survived to next therapy, including transplant (n = 13), durable LVAD (n = 15), and recovery of native heart function (n = 2). No strokes or major bleeding events requiring surgery were observed. Acute renal dysfunction, bleeding requiring transfusion, hemolysis, device malfunction, limb ischemia occurred in 13 (33%), 11 (28%), 3 (8%), 4 (10%), and 1 (3%) patients, respectively. Survival rate to discharge and/or 30 days was 68% (27 of 40). Temporary support with the Impella 5.0 allows for an effective bridge to decision strategy for hemodynamic stabilization and multidisciplinary heart team assessment of critically ill patients with heart failure. In conclusion, many of these patients can be subsequently bridged to the next therapy with favorable outcomes.

Frequency of Massive Cardiac Adiposity (Floating Heart) in the Native Hearts of Patients Having Heart Transplantation at a Single Texas Hospital (2013 to 2015) and Comparison of Various Clinical and Morphologic Variables in the Patients With Massive Versus Nonmassive Cardiac Adiposity

Body weight continues to increase worldwide due primarily to the increase in body fat. This study analyzes the frequency of massive adiposity at hearts of patients who underwent heart transplantation (HT) determined by the ability of the heart to float in a container of 10% formaldehyde (because adipose tissue is lighter than myocardium) and compares certain characteristics of those patients with and without floating hearts. The hearts studied at HT during a 3-year period (2013 to 2015) at Baylor University Medical Center were carefully "cleaned" and weighed by the same individual and tested as to their ability to float in a container of formaldehyde, an indication of severe cardiac adiposity. Of the 220 hearts studied, 84 (38%) floated in a container of formaldehyde and 136 (62%) did not. Comparison of the 84 patients with floating hearts to the 136 with nonfloating hearts showed a significant difference in ages, but a nonsignificant difference in gender, body mass index, frequency of systemic hypertension, or diabetes mellitus. The odds of a heart being a floating one was increased in patients with a diagnosis of ischemic cardiomyopathy (unadjusted odds ratio 2.12, 95% CI 1.21 to 3.70). The frequency of massive cardiac adiposity in the native hearts of patients having HT (38%) is striking and appears to have increased in frequency in the recent decades.

Atrophy of the Heart After Insertion of a Left Ventricular Assist Device and Closure of the Aortic Valve

Described are findings in a 70-year-old man who had heart transplantation 4 years after treatment with a left ventricular assist device, and surgical closure of his previously replaced aortic valve. The result was a totally nonfunctioning left ventricle resulting in severe atrophy.

Heart transplantation in the Ehlers-Danlos syndrome

We describe a woman with Ehlers-Danlos syndrome and aortic aneurysm who experienced a myocardial infarction due to spontaneous left circumflex coronary artery dissection 3 weeks postpartum. She developed end-stage heart failure and subsequently underwent a successful orthotopic heart transplantation. To our knowledge, this is the first report of a heart transplant performed in an individual with Ehlers-Danlos syndrome.

Usefulness of percutaneous closure of patent foramen ovale for hypoxia

We report a patient with hypoxia secondary to a right-to-left shunt through a patent foramen ovale, following aortic root, valve, and arch replacement due to an aortic dissection in the setting of the Marfan syndrome. Following the operation, he failed extubation twice due to hypoxia. An extensive workup revealed a right-to-left shunt previously not seen. The patent foramen ovale was closed using a percutaneous closure device. Following closure, our patient was extubated without difficulty and has done well postoperatively.

The two extremes of cardiac sarcoidosis and the effect of Prednisone therapy

Described herein are clinical and morphologic findings in 2 patients who underwent heart transplantation because of severe heart failure resulting from cardiac sarcoidosis. Although the explanted hearts in each patient had characteristic gross changes of cardiac sarcoidosis, one patient who had been treated with prednisone, had no residual sarcoid granulomas in the myocardium, whereas the other patient, in whom diagnosis was not made until heart transplantation, had innumerable sarcoid granulomas in her heart. This report suggests that prednisone can eliminate sarcoid granulomas in the heart but that their replacement is by dense fibrous tissue, something also likely the result of the granulomas themselves, creating a situation where the treated (prednisone) and the non-treated sarcoid heart may appear similar by gross examination.

Secondary arrhythmogenic right ventricular cardiomyopathy decades after operative repair of tetralogy of Fallot

We describe a 47-year-old man who underwent heart transplantation (HT) for severe right-sided heart failure and periodic episodes of ventricular tachycardia (VT) 43 years after operative repair of tetralogy of Fallot (T of F). The right-ventricular outflow tract, the site where a patch had been placed 4 decades earlier, was aneurysmal. Such development decades after operative repair of T of F of both aneurysm and episodes of VT is probably more common than previously realized.

Progression and remission of urologic symptoms in the community: results of a longitudinal cluster analysis approach

OBJECTIVE

To investigate the natural history of urologic symptom progression and remission by means of cluster analysis in a large, well-characterized cohort of men and women.

METHODS

Cluster analysis was used to assign men and women to symptom clusters on the basis of the prevalence of 14 self-reported urologic symptoms. Data were analyzed from the Boston Area Community Health study at baseline (T1) and 5-year follow-up (T2). Cluster progression was defined as any change from a less symptomatic to a more symptomatic cluster; conversely, cluster remission was defined as movement from more symptomatic to less symptomatic clusters. Logistic regression models examined the association of sociodemographic, psychosocial, and health outcome measures with cluster progression and remission.

RESULTS

Follow-up data were available from 4145 participants (1610 men; 2535 women). More than two thirds of men (69.2%) and women (68.2%) had stable symptom cluster assignments. Cluster progression occurred in 280 of 1610 (15.2%) men and 390 of 2535 (14.6%) women; cluster remission in 280 of 1610 (15.6%) men and 409 of 2535 (17.4%) women. In multivariate analyses, cluster progression was twice as common in men with incident depression (odds ratio = 2.43, 95% confidence interval 1.26-4.67) and 3 times more likely in men with ≥ 3 comorbidities at baseline. Urologic surgeries were uncommon in men and women and were not consistently related to cluster progression or remission.

CONCLUSION

Urologic symptom clusters were relatively stable over a 5-year follow-up period for more than two thirds of men and women in our sample. Specific risk factors for progression were identified in men and women.

Morphologic features of cardiac sarcoidosis in native hearts of patients having cardiac transplantation

Described herein are 10 patients who underwent cardiac transplantation (CT) for severe chronic systolic heart failure resulting from cardiac sarcoidosis. None had the diagnosis of sarcoidosis established before CT except for the 3 patients who earlier had had a portion of left ventricular wall excised for insertion of a left ventricular assist device and non-caseating granulomas were present in the removed myocardium. Although none of the 10 patients had significant narrowing of any of the epicardial coronary arteries, all had focal scarring of the walls of the left and right ventricles and ventricular septum and all had dilated ventricular cavities. The patients with the most ventricular wall scarring tended to have the fewest sarcoid granulomas in the ventricular walls. Two patients had no sarcoid granulomas in the excised heart although one did have typical sarcoid granulomas in the portion of left ventricular wall excised to insert a left ventricular assist device. Patients with cardiac sarcoidosis severe enough to warrant CT had characteristic cardiac ventricular morphologic findings, and no dysfunction of other non-cardiac organs, making clinical diagnosis of cardiac sarcoidosis rather difficult.

The myth of the Bernheim syndrome

The Bernheim syndrome has been a topic of discussion for over a century. It has been reported to be caused by severe rightward movement of the ventricular septum resulting in compression of the right ventricular cavity leading to right-sided heart failure without pulmonary congestion. Hemodynamic findings have been described in a few patients with the so-called Bernheim syndrome. We describe a patient in whom the ventricular septum dramatically decreased the size of the right ventricular cavity and yet peak systolic pressures in both the right ventricle and pulmonary trunk were identical. Thus, it is difficult to view the Bernheim syndrome as a real entity.

Dramatically different phenotypic expressions of hypertrophic cardiomyopathy in male cousins undergoing cardiac transplantation with identical disease-causing gene mutation

Described herein are certain findings in 2 male cousins who underwent cardiac transplantation for severe heart failure (HF), one of the diastolic type (ejection fraction ≈65%), and one of the systolic type (ejection fraction ≈20%), both the consequence of hypertrophic cardiomyopathy (HC), and each had identical disease-causing gene mutations. The implanted heart in one had normal-sized ventricular cavities and no grossly visible ventricular wall lesions (except in one papillary muscle) and the other patient had severely dilated ventricular cavities and multiple extensive ventricular wall scars. The heart mass and the age of onset of symptoms was similar in each patient. A number of other family members had evidence of HC.

Trajectories of change in sagebrush steppe vegetation communities in relation to multiple wildfires

Repeated perturbations, both biotic and abiotic, can lead to fundamental changes in the nature of ecosystems, including changes in state. Sagebrush steppe communities provide important habitat for wildlife and grazing for livestock. Fire is an integral part of these systems, but there is concern that increased ignition frequencies and invasive species are fundamentally altering them. Despite these issues, the majority of studies of fire effects in systems dominated by Artemisia tridentata wyomingensis have focused on the effects of single burns. The Arid Lands Ecology Reserve (ALE), in south-central Washington (U.S.A.), was one of the largest contiguous areas of sagebrush steppe habitat in the state until large wildfires burned the majority of it in 2000 and 2007. We analyzed data from permanent vegetation transects established in 1996 and resampled in 2002 and 2009. Our objective was to describe how the fires, and subsequent postfire restoration efforts, affected communities' successional pathways. Plant communities differed in response to repeated fire and restoration; these differences could largely be ascribed to the functional traits of the dominant species. Low-elevation communities, previously dominated by obligate seeders, moved furthest from their initial composition and were dominated by weedy, early-successional species in 2009. Higher-elevation sites with resprouting shrubs, native bunchgrasses, and few invasive species were generally more resilient to the effects of repeated disturbances. Shrub cover has been almost entirely removed from ALE, although there was some recovery where communities were dominated by resprouters. Bromus tectorum dominance was reduced by herbicide application in areas where it was previously abundant, but it increased significantly in untreated areas. Several resprouting species, notably Phlox longifolia and Poa secunda, expanded remarkably following competitive release from shrub canopies and/or abundant B. tectorum. Our results suggest that community dynamics can be understood through a state and transition model with two axes (shrub/grass and native/invasive abundance), although such models also need to account for differences in plant functional traits and disturbance regimes. We use our results to develop a conceptual model that will be validated with further research.

Relative contributions of multiple determinants to bone mineral density in men

SUMMARY

Focus on individual risk factors for osteoporosis could allocate disproportionate attention to trivial relationships. We tested many recognized risk factors of osteoporosis for their association with bone mineral density (BMD) in multivariate models among men. Lean mass accounted for the most variance, with substantially less accounted for by demographic, strength, and health factors.

INTRODUCTION

Osteoporosis in men has gained recognition as a public health problem, generating an interest in the search for risk factors. Isolation of individual risk factors could allocate disproportionate attention to relationships that may be of limited consequence.

METHODS

The Boston Area Community Health/Bone (BACH/Bone) Survey is a population-based study of randomly selected community-dwelling men (age, 30-79 years). BMD and lean mass were measured by dual X-ray absorptiometry. Socioeconomic status, health history, and lifestyle factors were obtained via interview. Hormone levels and markers of bone turnover were obtained from non-fasting blood samples. Multivariate analyses measured relative contributions of covariates to femoral neck (hip), one-third distal radius (wrist), and lumbar spine BMD.

RESULTS

Factors positively associated with BMD in multivariate models at the three sites were black race and appendicular lean mass. Asthma was consistently negatively associated. Various other risk factors also contributed significantly to each of the individual sites. R (2) values for the hip, wrist, and spine were 41%, 30%, and 24%, respectively. Lean mass accounted for the most explained variance at all three sites.

CONCLUSIONS

These data emphasize the limitation of focusing on individual risk factors and highlight the importance of potentially modifiable lean mass in predicting BMD.

Litter and dead wood dynamics in ponderosa pine forests along a 160-year chronosequence

Disturbances such as fire play a key role in controlling ecosystem structure. In fire-prone forests, organic detritus comprises a large pool of carbon and can control the frequency and intensity of fire. The ponderosa pine forests of the Colorado Front Range, USA, where fire has been suppressed for a century, provide an ideal system for studying the long-term dynamics of detrital pools. Our objectives were (1) to quantify the long-term temporal dynamics of detrital pools; and (2) to determine to what extent present stand structure, topography, and soils constrain these dynamics. We collected data on downed dead wood, litter, duff (partially decomposed litter on the forest floor), stand structure, topographic position, and soils for 31 sites along a 160-year chronosequence. We developed a compartment model and parameterized it to describe the temporal trends in the detrital pools. We then developed four sets of statistical models, quantifying the hypothesized relationship between pool size and (1) stand structure, (2) topography, (3) soils variables, and (4) time since fire. We contrasted how much support each hypothesis had in the data using Akaike's Information Criterion (AIC). Time since fire explained 39-80% of the variability in dead wood of different size classes. Pool size increased to a peak as material killed by the fire fell, then decomposed rapidly to a minimum (61-85 years after fire for the different pools). It then increased, presumably as new detritus was produced by the regenerating stand. Litter was most strongly related to canopy cover (r2 = 77%), suggesting that litter fall, rather than decomposition, controls its dynamics. The temporal dynamics of duff were the hardest to predict. Detrital pool sizes were more strongly related to time since fire than to environmental variables. Woody debris peak-to-minimum time was 46-67 years, overlapping the range of historical fire return intervals (1 to > 100 years). Fires may therefore have burned under a wide range of fuel conditions, supporting the hypothesis that this region's fire regime was mixed severity.

Effects of Cardiac Resynchronization on Disease Progression in Patients With Left Ventricular Systolic Dysfunction, an Indication for an Implantable Cardioverter-Defibrillator, and Mildly Symptomatic Chronic Heart Failure

Background— The effects of cardiac resynchronization therapy (CRT) in patients with mildly symptomatic heart failure have not been fully elucidated.

Methods and Results— The Multicenter InSync ICD Randomized Clinical Evaluation II (MIRACLE ICD II) was a randomized, double-blind, parallel-controlled clinical trial of CRT in NYHA class II heart failure patients on optimal medical therapy with a left ventricular (LV) ejection fraction ≤35%, a QRS ≥130 ms, and a class I indication for an ICD. One hundred eighty-six patients were randomized: 101 to the control group (ICD activated, CRT off) and 85 to the CRT group (ICD activated, CRT on). End points included peak V̇ o 2 , V̇ e /V̇ co 2 , NYHA class, quality of life, 6-minute walk distance, LV volumes and ejection fraction, and composite clinical response. Compared with the control group at 6 months, no significant improvement was noted in peak V̇ o 2 , yet there were significant improvements in ventricular remodeling indexes, specifically LV diastolic and systolic volumes ( P =0.04 and P =0.01, respectively), and LV ejection fraction ( P =0.02). CRT patients showed statistically significant improvement in V̇ e /V̇ co 2 ( P =0.01), NYHA class ( P =0.05), and clinical composite response ( P =0.01). No significant differences were noted in 6-minute walk distance or quality of life scores.

Conclusions— In patients with mild heart failure symptoms on optimal medical therapy with a wide QRS complex and an ICD indication, CRT did not alter exercise capacity but did result in significant improvement in cardiac structure and function and composite clinical response over 6 months.