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Pouliopoulos J, Anthony C, Imran M, Graham RM, McCrohon J, Holloway C, Kotlyar E, Muthiah K, Keogh AM, Hayward CS, Macdonald PS, Jabbour A. Cost-Effectiveness of Cardiovascular Magnetic Resonance for Rejection Surveillance After Cardiac Transplantation in the Australian Health Care System. Heart Lung Circ 2024:S1443-9506(24)00164-1. [PMID: 38604884 DOI: 10.1016/j.hlc.2024.03.004] [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] [Received: 10/17/2023] [Revised: 02/07/2024] [Accepted: 03/02/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Heart transplantation is an effective treatment for end-stage congestive heart failure, however, achieving the right balance of immunosuppression to maintain graft function while minimising adverse effects is challenging. Serial endomyocardial biopsies (EMBs) are currently the standard for rejection surveillance, despite being invasive. Replacing EMB-based surveillance with cardiac magnetic resonance (CMR)-based surveillance for acute cardiac allograft rejection has shown feasibility. This study aimed to assess the cost-effectiveness of CMR-based surveillance in the first year after heart transplantation. METHOD A prospective clinical trial was conducted with 40 orthotopic heart transplant (OHT) recipients. Participants were randomly allocated into two surveillance groups: EMB-based, and CMR-based. The trial included economic evaluations, comparing the frequency and cost of surveillance modalities in relation to quality-adjusted life years (QALYs) within the first year post-transplantation. Sensitivity analysis encompassed modelled data from observed EMB and CMR arms, integrating two hypothetical models of expedited CMR-based surveillance. RESULTS In the CMR cohort, 238 CMR scans and 15 EMBs were conducted, versus (vs) 235 EMBs in the EMB group. CMR surveillance yielded comparable rejection rates (CMR 74 vs EMB 94 events, p=0.10) and did not increase hospitalisation risk (CMR 32 vs EMB 46 events, p=0.031). It significantly reduced the necessity for invasive EMBs by 94%, lowered costs by an average of AUD$32,878.61, and enhanced cumulative QALY by 0.588 compared with EMB. Sensitivity analysis showed that increased surveillance with expedited CMR Models 1 and 2 were more cost-effective than EMB (all p<0.01), with CMR Model 1 achieving the greatest cost savings (AUD$34,091.12±AUD$23,271.86 less) and utility increase (+0.62±1.49 QALYs, p=0.011), signifying an optimal cost-utility ratio. Model 2 showed comparable utility to the base CMR model (p=0.900) while offering the benefit of heightened surveillance frequency during periods of elevated rejection risk. CONCLUSIONS CMR-based rejection surveillance in orthotopic heart transplant recipients provides a cost-effective alternative to EMB-based surveillance. Furthermore, it reduces the need for invasive procedures, without increased risk of rejection or hospitalisation for patients, and can be incorporated economically for expedited surveillance. These findings have important implications for improving patient care and optimising resource allocation in post-transplant management.
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Affiliation(s)
- Jim Pouliopoulos
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia; School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Chris Anthony
- Alfred Health and Monash University, Melbourne, Vic, Australia
| | - Muhammad Imran
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Robert M Graham
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, NSW, Australia; School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia; Alfred Health and Monash University, Melbourne, Vic, Australia
| | - Jane McCrohon
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Cameron Holloway
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Eugene Kotlyar
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Kavitha Muthiah
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Anne M Keogh
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, NSW, Australia; School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Christopher S Hayward
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - Peter S Macdonald
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia; School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Andrew Jabbour
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia; School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia.
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Gunawan A, Robson D, Krishnaswamy RJ, Ramanayake A, Kearney K, Muthiah K, Jain P, Adji A, Hayward CS. Longitudinal analysis left ventricular chamber responses under durable LVAD support. J Heart Lung Transplant 2024; 43:420-431. [PMID: 37844674 DOI: 10.1016/j.healun.2023.10.004] [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: 05/11/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND Left ventricular assist device (LVAD) support offers remodeling potential in some patients. Our goal was to use noninvasively derived pressure-volume (PV) loops to understand the effect of demographic and device variables on serial changes in cardiac function under pump support. METHODS Thirty-two consecutive Medtronic HeartWare Ventricular Assist Device (HVAD) patients (mean 55.9 ± 12.3 years, 81.3% male) were prospectively recruited. Single-cycle ventricular pressure and volume were estimated using a validated algorithm. PV loops (n = 77) and corresponding cardiac chamber dynamics were derived at predefined postimplant timepoints (1, 3, 6 months). Changes in PV loop parameters sustained across the 6-month period were characterized using mixed-effects modeling. The influence of demographic and device variables on the observed changes was assessed. RESULTS Across a 6-month period, the mean ventricular function parameters remained stable. Significant predictors of monthly improvement of stroke work include: lower pump speeds (2400 rpm vs 2500-2800 rpm) [0.0.051 mm Hg/liter/month (p = 0.001)], high pulsatility index (>1.0 vs <1.0) [0.052 mm Hg/liter/month (p = 0.012)], and ischemic cardiomyopathy indication for LVAD implantation (vs nonischemic) [0.0387 mm Hg/liter/month (p = 0.007)]. Various other cardiac chamber function parameters including cardiac power, peak systolic pressure, and LV elastance also showed improvements in these cohorts. CONCLUSIONS Factors associated with improvement in ventricular energetics and hemodynamics under LVAD support can be determined with noninvasive PV loops. Understanding the basis of increasing ventricular load to optimize myocardial remodeling may prove valuable in selecting eligible recovery candidates.
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Affiliation(s)
- Aaron Gunawan
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia
| | - Desiree Robson
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
| | - Rohan J Krishnaswamy
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia
| | - Anju Ramanayake
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia
| | - Katherine Kearney
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia; Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Kavitha Muthiah
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia; Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Pankaj Jain
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
| | - Audrey Adji
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia; Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Christopher S Hayward
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; St Vincent's Clinical School, UNSW, Sydney, Australia; Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia.
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Barua S, Hayward CS, Macdonald PS. Simultaneous Heart and Kidney Transplantation for LVAD-supported Patients With Chronic Kidney Disease? Transplantation 2024; 108:331-332. [PMID: 37677940 DOI: 10.1097/tp.0000000000004782] [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: 09/09/2023]
Affiliation(s)
- Sumita Barua
- Heart Lung Transplant Unit, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
- School of Medicine, St. Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
| | - Christopher S Hayward
- Heart Lung Transplant Unit, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
- School of Medicine, St. Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Peter S Macdonald
- Heart Lung Transplant Unit, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
- School of Medicine, St. Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
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Bart NK, Robson D, Muthiah K, Jansz PC, Hayward CS. How do mechanical circulatory support patients die? Autopsy findings for left-ventricular assist device/total artificial heart nonsurvivors. J Heart Lung Transplant 2023; 42:1753-1763. [PMID: 37422144 DOI: 10.1016/j.healun.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 06/03/2023] [Accepted: 07/02/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND Although life saving for end-stage heart failure patients, permanent mechanical circulatory support (MCS) is often the proximate cause of death in those that do not survive to transplant. Autopsy remains the gold standard for diagnosing causes of death and a vital tool for better understanding underlying pathology of nonsurvivors. The aim of this study was to determine the frequency and outcomes of autopsy investigations and compare these with premortem clinical assessment. METHODS The autopsy findings and medical records of all patients who underwent left ventricular assist device (LVAD) or total artificial heart (TAH) insertion between June 1994 and April 2022 as a bridge to transplant, but subsequently died pre-heart transplantation were reviewed. RESULTS A total of 203 patients had a LVAD or TAH implanted during the study period. Seventy-eight patients (M=59, F=19) died prior to transplantation (age 55 [14] years, INTERMACS=2). Autopsies were conducted in 26 of 78 patients (33%). Three were limited studies. The leading contributor to cause of death was respiratory (14/26), either nosocomial infection or associated with multiorgan failure. Intracranial hemorrhage was the second most common cause of death (8/26). There was a major discrepancy rate of 17% and a minor discrepancy rate of 43%. Autopsy study added a total of 14 additional contributors of death beyond clinical assessment alone (Graphical Abstract). CONCLUSIONS Over an observational period of 26years, the frequency of autopsy was low. To improve LVAD/TAH patient survival to transplant, better understanding as to cause of death is required. Patients with MCS have complex physiology and are at high risk of infection and bleeding complications.
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Affiliation(s)
- Nicole K Bart
- St Vincent's Hospital, Sydney, New South Wales, Australia; Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia; Notre Dame University, Sydney, New South Wales, Australia.
| | - Desire Robson
- St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Kavitha Muthiah
- St Vincent's Hospital, Sydney, New South Wales, Australia; Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia
| | - Paul C Jansz
- St Vincent's Hospital, Sydney, New South Wales, Australia; Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia
| | - Christopher S Hayward
- St Vincent's Hospital, Sydney, New South Wales, Australia; Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia
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Barua S, Conte SM, Cherrett C, Kearney KL, Robson D, Bragg C, Macdonald PS, Muthiah K, Hayward CS. Major adverse kidney events predict reduced survival in ventricular assist device supported patients. ESC Heart Fail 2023; 10:3463-3471. [PMID: 37712126 PMCID: PMC10682875 DOI: 10.1002/ehf2.14533] [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: 07/22/2023] [Accepted: 08/30/2023] [Indexed: 09/16/2023] Open
Abstract
AIMS There is limited data describing major adverse kidney events (MAKE) in patients supported with ventricular assist devices (VAD). We aim to describe the association between MAKE and survival, risk factors for MAKE, and renal trajectory in VAD supported patients. METHODS AND RESULTS We conducted a single-centre retrospective analysis of consecutive VAD implants between 2010 and 2019. Baseline demographics, biochemistry, and adverse events were collected for the duration of VAD support. MAKE was defined as the first event to occur of sustained drop (>50%) in estimated glomerular filtration rate (eGFR), progression to stage V chronic kidney disease, initiation or continuation of renal replacement therapy beyond implant admission or death on renal replacement therapy at any time. One-hundred and seventy-three patients were included, median age 56.8 years, 18.5% female, INTERMACS profile 1 or 2 in 75.1%. Thirty-seven patients experienced MAKE. On multivariate analysis, post-implant clinical right ventricular failure and the presence of chronic haemolysis, defined by the presence of schistocytes on blood film analysis, were significantly associated with increased risk of MAKE (adjusted odds ratio 9.88, P < 0.001 and adjusted odds ratio 3.33, P = 0.006, respectively). MAKE was associated with reduced survival (hazard ratio 4.80, P < 0.001). Patients who died or experienced MAKE did not demonstrate the expected transient 3-month improvement in eGFR, seen in other cohorts. CONCLUSIONS MAKE significantly impacts survival. In our cohort, MAKE was predicted by post-implant right ventricular failure and chronic haemolysis. The lack of early eGFR improvement on VAD support may indicate higher risk for MAKE.
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Affiliation(s)
- Sumita Barua
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
- Cardiac Mechanics LaboratoryVictor Chang Cardiac Research InstituteSydneyAustralia
| | - Sean M. Conte
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
- School of MedicineUniversity of Notre Dame AustraliaSydneyAustralia
| | - Callum Cherrett
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
| | - Katherine L. Kearney
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
- Cardiac Mechanics LaboratoryVictor Chang Cardiac Research InstituteSydneyAustralia
- Department of CardiologyRoyal Prince Alfred HospitalSydneyAustralia
| | - Desiree Robson
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
| | | | - Peter S. Macdonald
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
- Cardiac Mechanics LaboratoryVictor Chang Cardiac Research InstituteSydneyAustralia
| | - Kavitha Muthiah
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
- Cardiac Mechanics LaboratoryVictor Chang Cardiac Research InstituteSydneyAustralia
| | - Christopher S. Hayward
- Heart and Lung Transplant UnitSt Vincent's HospitalSydneyAustralia
- School of MedicineUniversity of New South Wales SchoolSydneyAustralia
- Cardiac Mechanics LaboratoryVictor Chang Cardiac Research InstituteSydneyAustralia
- Faculty of HealthUniversity of TechnologySydneyAustralia
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Chavali S, Barua S, Adji A, Robson D, Raven LM, Greenfield JR, Eckford H, Macdonald PS, Hayward CS, Muthiah K. Safety and tolerability of sodium-glucose cotransporter-2 inhibitors in bridge-to-transplant patients supported with centrifugal-flow left ventricular assist devices. Int J Cardiol 2023; 391:131259. [PMID: 37574028 DOI: 10.1016/j.ijcard.2023.131259] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 08/02/2023] [Accepted: 08/10/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND The safety and tolerability of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in patients with end-stage heart failure supported with left-ventricular-assist-devices (LVADs), irrespective of diabetes mellitus, is not known. METHODS A retrospective analysis of 31 outpatients implanted with LVADs as bridge-to-transplant (BTT) was conducted. Patients with biventricular support, aged under 18 years, who were discharged from the index hospitalisation, or were prescribed SGLT2i prior to their first outpatient clinic were excluded. Patient demographics, laboratory studies, pump haemodynamic and adverse event data was collected. RESULTS Sixteen (51.6%) of 31 patients were prescribed SGLT2i over median 101.5 days (37.5-190.8). No patients discontinued SGLT2i use or reported attributable adverse symptoms. No significant differences between patients prescribed SGLT2i compared to those SGLT2i-naïve were seen in: [1] renal function; [2] weight; [3] mean arterial pressure. There were numerically lower infection-related (n = 4 vs 7, HR 0.32 (0.08-1.28), p = 0.11) and haemocompatibility-related (n = 3 vs 4, HR 0.52 (0.09-2.83), p = 0.45) adverse events in the SGLT2i group, albeit non-significant. CONCLUSIONS We found SGLT2i to be safe and well-tolerated in the BTT LVAD cohort with no significant difference in rates of infection or haemocompatibility-related adverse events with SGLT2i use. Larger studies will inform further beneficial effects of SGLT2i prescription in this cohort.
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Affiliation(s)
- Sanjay Chavali
- St Vincent's Hospital, Sydney, Australia; School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Sumita Barua
- St Vincent's Hospital, Sydney, Australia; School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Audrey Adji
- St Vincent's Hospital, Sydney, Australia; School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia
| | | | - Lisa M Raven
- St Vincent's Hospital, Sydney, Australia; School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Clinical Diabetes, Appetite and Metabolism Laboratory, Garvan Institute of Medical Research, Sydney, Australia
| | - Jerry R Greenfield
- St Vincent's Hospital, Sydney, Australia; School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Clinical Diabetes, Appetite and Metabolism Laboratory, Garvan Institute of Medical Research, Sydney, Australia
| | - Hunter Eckford
- St Vincent's Hospital, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Peter S Macdonald
- St Vincent's Hospital, Sydney, Australia; School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Christopher S Hayward
- St Vincent's Hospital, Sydney, Australia; School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Kavitha Muthiah
- St Vincent's Hospital, Sydney, Australia; School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia.
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Cowger JA, Basir MB, Baran DA, Hayward CS, Rangaswami J, Walton A, Tita C, Minear S, Hakemi E, Klein L, Cheng R, Wu R, Mohanty BD, Heuring JJ, Neely E, Shah P. Safety and Performance of the Aortix Device in Acute Decompensated Heart Failure and Cardiorenal Syndrome. JACC Heart Fail 2023; 11:1565-1575. [PMID: 37804307 DOI: 10.1016/j.jchf.2023.06.018] [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] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND Cardiorenal syndrome (CRS) complicates 33% of acute decompensated heart failure (ADHF) admissions, and patients with persistent congestion at discharge have high 30-day event rates. OBJECTIVES The purpose of this study was to evaluate a novel catheter-deployed intra-aortic entrainment pump (IAEP) in patients with ADHF with CRS and persistent congestion. METHODS A multicenter (n = 14), nonrandomized, single-arm, safety and feasibility study of IAEP therapy was conducted. Within patient changes (post-pre IAEP therapy) in fluid loss, hemodynamics, patient-reported dyspnea, and serum biomarkers were assessed using Wilcoxon signed-rank testing. RESULTS Of 21 enrolled patients, 18 received Aortix therapy. Mean ± SD patient age was 60.3 ± 7.9 years. The median left ventricular ejection fraction was 22.5% (25th-75th percentile: 10.0%-53.5%); 27.8% had a left ventricular ejection fraction ≥50%. Pre-therapy, patients received 8.7 ± 4.1 days of loop diuretic agents and 44% were on inotropes. Pump therapy averaged 4.6 ± 1.6 days, yielding net fluid losses of 10.7 ± 6.5 L (P < 0.001) and significant (P < 0.01) reductions in central venous pressure (change from baseline: -8.5 mm Hg [25th-75th percentile: -3.5 to -10.0 mm Hg]), pulmonary capillary wedge pressure (-11.0 mm Hg [25th-75th percentile: -5.0 to -14.0 mm Hg]), and serum creatinine (-0.2 mg/dL [25th-75th percentile: -0.1 to -0.5 mg/dL]) with improved estimated glomerular filtration rate (+5.0 mL/min/1.73 m2 [25th-75th percentile: 2.0-9.0 mL/min/1.73 m2]) and patient-reported dyspnea score (+16 [25th-75th percentile: 3-37]). Dyspnea scores, natriuretic peptides, and renal function improvements persisted through 30 days. CONCLUSIONS This pilot study of patients with ADHF, persistent congestion, and worsening renal function due to CRS supports the potential for safely achieving decongestion using IAEP therapy. These initial promising results provide the basis for future randomized clinical trials of this novel pump. (An Evaluation of the Safety and Performance of the Aortix System for Intra-Aortic Mechanical Circulatory Support in Patients with Cardiorenal Syndrome [The Aortix CRS Pilot Study]; NCT04145635).
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Affiliation(s)
- Jennifer A Cowger
- Henry Ford Health Heart and Vascular Institute, Detroit, Michigan, USA
| | - Mir B Basir
- Henry Ford Health Heart and Vascular Institute, Detroit, Michigan, USA
| | | | - Christopher S Hayward
- St. Vincent's Hospital, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia
| | | | | | - Cristina Tita
- Henry Ford Health Heart and Vascular Institute, Detroit, Michigan, USA
| | | | - Emad Hakemi
- Cleveland Clinic Florida, Weston, Florida, USA
| | - Liviu Klein
- University of California San Francisco, San Francisco, California, USA
| | - Richard Cheng
- University of California San Francisco, San Francisco, California, USA
| | - Robby Wu
- Tampa General Hospital and University of South Florida Heart and Vascular Institute, Tampa, Florida, USA
| | - Bibhu D Mohanty
- Tampa General Hospital and University of South Florida Heart and Vascular Institute, Tampa, Florida, USA
| | | | | | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA.
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Johnson R, Otway R, Chin E, Horvat C, Ohanian M, Wilcox JA, Su Z, Prestes P, Smolnikov A, Soka M, Guo G, Rath E, Chakravorty S, Chrzanowski L, Hayward CS, Keogh AM, Macdonald PS, Giannoulatou E, Chang AC, Oates EC, Charchar F, Seidman JG, Seidman CE, Hegde M, Fatkin D. DMD-Associated Dilated Cardiomyopathy: Genotypes, Phenotypes, and Phenocopies. Circ Genom Precis Med 2023; 16:421-430. [PMID: 37671549 PMCID: PMC10592075 DOI: 10.1161/circgen.123.004221] [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] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 07/31/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Variants in the DMD gene, that encodes the cytoskeletal protein, dystrophin, cause a severe form of dilated cardiomyopathy (DCM) associated with high rates of heart failure, heart transplantation, and ventricular arrhythmias. Improved early detection of individuals at risk is needed. METHODS Genetic testing of 40 male probands with a potential X-linked genetic cause of primary DCM was undertaken using multi-gene panel sequencing, multiplex polymerase chain reaction, and array comparative genomic hybridization. Variant location was assessed with respect to dystrophin isoform patterns and exon usage. Telomere length was evaluated as a marker of myocardial dysfunction in left ventricular tissue and blood. RESULTS Four pathogenic/likely pathogenic DMD variants were found in 5 probands (5/40: 12.5%). Only one rare variant was identified by gene panel testing with 3 additional multi-exon deletion/duplications found following targeted assays for structural variants. All of the pathogenic/likely pathogenic DMD variants involved dystrophin exons that had percent spliced-in scores >90, indicating high levels of constitutive expression in the human adult heart. Fifteen DMD variant-negative probands (15/40: 37.5%) had variants in autosomal genes including TTN, BAG3, LMNA, and RBM20. Myocardial telomere length was reduced in patients with DCM irrespective of genotype. No differences in blood telomere length were observed between genotype-positive family members with/without DCM and controls. CONCLUSIONS Primary genetic testing using multi-gene panels has a low yield and specific assays for structural variants are required if DMD-associated cardiomyopathy is suspected. Distinguishing X-linked causes of DCM from autosomal genes that show sex differences in clinical presentation is crucial for informed family management.
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Affiliation(s)
- Renee Johnson
- Victor Chang Cardiac Rsrch Inst, Darlinghurst
- School of Clinical Medicine, Faculty of Medicine & Health, UNSW Sydney, Kensington, NSW, Australia
| | - Robyn Otway
- Victor Chang Cardiac Rsrch Inst, Darlinghurst
| | - Ephrem Chin
- Dept of Human Genetics, Emory Univ School of Medicine, Atlanta GA
- PerkinElmer Genomics, PerkinElmer, Waltham
| | | | | | | | - Zheng Su
- School of Biotechnology & Biomolecular Sciences, Faculty of Science, UNSW Sydney, Kensington, NSW, Australia
| | - Priscilla Prestes
- Health Innovation & Transformation Ctr, Federation Univ Australia, Ballarat, Victoria, Australia
| | - Andrei Smolnikov
- School of Biotechnology & Biomolecular Sciences, Faculty of Science, UNSW Sydney, Kensington, NSW, Australia
| | | | | | - Emma Rath
- Victor Chang Cardiac Rsrch Inst, Darlinghurst
- School of Clinical Medicine, Faculty of Medicine & Health, UNSW Sydney, Kensington, NSW, Australia
| | - Samya Chakravorty
- Dept of Human Genetics, Emory Univ School of Medicine, Atlanta GA
- Biocon Bristol Myers Squibb Rsrch & Development Ctr (BBRC), Bangalore, India
| | | | - Christopher S. Hayward
- Victor Chang Cardiac Rsrch Inst, Darlinghurst
- School of Clinical Medicine, Faculty of Medicine & Health, UNSW Sydney, Kensington, NSW, Australia
- Cardiology Dept, St Vincent’s Hospital, Darlinghurst, NSW, Australia
| | - Anne M. Keogh
- Victor Chang Cardiac Rsrch Inst, Darlinghurst
- School of Clinical Medicine, Faculty of Medicine & Health, UNSW Sydney, Kensington, NSW, Australia
- Cardiology Dept, St Vincent’s Hospital, Darlinghurst, NSW, Australia
| | - Peter S. Macdonald
- Victor Chang Cardiac Rsrch Inst, Darlinghurst
- School of Clinical Medicine, Faculty of Medicine & Health, UNSW Sydney, Kensington, NSW, Australia
- Cardiology Dept, St Vincent’s Hospital, Darlinghurst, NSW, Australia
| | - Eleni Giannoulatou
- Victor Chang Cardiac Rsrch Inst, Darlinghurst
- School of Clinical Medicine, Faculty of Medicine & Health, UNSW Sydney, Kensington, NSW, Australia
| | - Alex C.Y. Chang
- Dept of Cardiology & Shanghai Inst of Precision Medicine, Ninth People’s Hospital, Shanghai Jiao Tong Univ School of Medicine, Shanghai, China
- Baxter Laboratory for Stem Cell Biology, Dept of Microbiology & Immunology, Inst for Stem Cell Biology & Regenerative Medicine, Stanford Univ School of Medicine, Stanford, CA
| | - Emily C. Oates
- School of Biotechnology & Biomolecular Sciences, Faculty of Science, UNSW Sydney, Kensington, NSW, Australia
| | - Fadi Charchar
- Health Innovation & Transformation Ctr, Federation Univ Australia, Ballarat, Victoria, Australia
| | - Jonathan G. Seidman
- Dept of Genetics, Harvard Medical School, Boston, MA
- Howard Hughes Medical Inst, Boston
| | - Christine E. Seidman
- Dept of Genetics, Harvard Medical School, Boston, MA
- Cardiovascular Division, Brigham and Women’s Hospital, Boston MA
| | - Madhuri Hegde
- Dept of Human Genetics, Emory Univ School of Medicine, Atlanta GA
- PerkinElmer Genomics, PerkinElmer, Waltham
| | - Diane Fatkin
- Victor Chang Cardiac Rsrch Inst, Darlinghurst
- School of Clinical Medicine, Faculty of Medicine & Health, UNSW Sydney, Kensington, NSW, Australia
- Cardiology Dept, St Vincent’s Hospital, Darlinghurst, NSW, Australia
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9
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Raven LM, Muir CA, Pouliopoulos J, Hayward CS, Macdonald PS, Greenfield JR, Jabbour A. Metabolic Sequelae of Everolimus Treatment After Cardiac Transplant: A Hypothesis-Generating Study. Heart Lung Circ 2023; 32:1076-1079. [PMID: 37355429 DOI: 10.1016/j.hlc.2023.05.014] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/16/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Although modern immunosuppressants improve survival post-transplant, they are associated with long-term metabolic complications, such as post-transplant diabetes mellitus (PTDM). Calcineurin inhibitor-sparing regimens using everolimus attenuate some complications such as left ventricular hypertrophy. However, the metabolic effects of everolimus following transplant are less clear. METHODS Post-hoc analysis to compare PTDM and other metabolic outcomes in participants of a randomised open-label clinical trial of low-dose everolimus and tacrolimus versus standard-dose tacrolimus in heart transplant recipients (RADTAC1 study). RESULTS There were 39 participants in the trial; mean follow-up was 6.4±1.5 years. There was a high rate of pre-existing diabetes (26%) and newly diagnosed PTDM (36%) during follow-up. Half the patients who developed PTDM in the everolimus-tacrolimus group (n=4/8) ceased diabetes medications during follow-up, which was not observed in patients on standard tacrolimus (n=0/6). In the first 12 months there was a higher use of non-insulin treatment for diabetes in the everolimus-tacrolimus group compared to the standard tacrolimus group. CONCLUSIONS This study suggests that treatment with everolimus may be associated with improved glycaemic control of PTDM relative to treatment with standard doses of calcineurin inhibitor. These findings should be further studied in prospective randomised trials.
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Affiliation(s)
- Lisa M Raven
- Department of Diabetes and Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia; Clinical Diabetes, Appetite and Metabolism Laboratory, Garvan Institute of Medical Research, Sydney, NSW, Australia; School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.
| | - Christopher A Muir
- Department of Diabetes and Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia; School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Jim Pouliopoulos
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia; Department of Heart and Lung Transplantation, St Vincent's Hospital, Sydney, NSW, Australia
| | - Christopher S Hayward
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia; Department of Heart and Lung Transplantation, St Vincent's Hospital, Sydney, NSW, Australia
| | - Peter S Macdonald
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia; Department of Heart and Lung Transplantation, St Vincent's Hospital, Sydney, NSW, Australia
| | - Jerry R Greenfield
- Department of Diabetes and Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia; Clinical Diabetes, Appetite and Metabolism Laboratory, Garvan Institute of Medical Research, Sydney, NSW, Australia; School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Andrew Jabbour
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia; Department of Heart and Lung Transplantation, St Vincent's Hospital, Sydney, NSW, Australia
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10
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Namasivayam M, Meredith T, Muller DWM, Roy DA, Roy AK, Kovacic JC, Hayward CS, Feneley MP. Machine learning prediction of progressive subclinical myocardial dysfunction in moderate aortic stenosis. Front Cardiovasc Med 2023; 10:1153814. [PMID: 37324638 PMCID: PMC10266266 DOI: 10.3389/fcvm.2023.1153814] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 05/15/2023] [Indexed: 06/17/2023] Open
Abstract
Background Moderate severity aortic stenosis (AS) is poorly understood, is associated with subclinical myocardial dysfunction, and can lead to adverse outcome rates that are comparable to severe AS. Factors associated with progressive myocardial dysfunction in moderate AS are not well described. Artificial neural networks (ANNs) can identify patterns, inform clinical risk, and identify features of importance in clinical datasets. Methods We conducted ANN analyses on longitudinal echocardiographic data collected from 66 individuals with moderate AS who underwent serial echocardiography at our institution. Image phenotyping involved left ventricular global longitudinal strain (GLS) and valve stenosis severity (including energetics) analysis. ANNs were constructed using two multilayer perceptron models. The first model was developed to predict change in GLS from baseline echocardiography alone and the second to predict change in GLS using data from baseline and serial echocardiography. ANNs used a single hidden layer architecture and a 70%:30% training/testing split. Results Over a median follow-up interval of 1.3 years, change in GLS (≤ or >median change) could be predicted with accuracy rates of 95% in training and 93% in testing using ANN with inputs from baseline echocardiogram data alone (AUC: 0.997). The four most important predictive baseline features (reported as normalized % importance relative to most important feature) were peak gradient (100%), energy loss (93%), GLS (80%), and DI < 0.25 (50%). When a further model was run including inputs from both baseline and serial echocardiography (AUC 0.844), the top four features of importance were change in dimensionless index between index and follow-up studies (100%), baseline peak gradient (79%), baseline energy loss (72%), and baseline GLS (63%). Conclusions Artificial neural networks can predict progressive subclinical myocardial dysfunction with high accuracy in moderate AS and identify features of importance. Key features associated with classifying progression in subclinical myocardial dysfunction included peak gradient, dimensionless index, GLS, and hydraulic load (energy loss), suggesting that these features should be closely evaluated and monitored in AS.
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Affiliation(s)
- Mayooran Namasivayam
- Department of Cardiology, St Vincent’s Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Heart Valve Disease and Artificial Intelligence Laboratory, Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - Thomas Meredith
- Department of Cardiology, St Vincent’s Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Heart Valve Disease and Artificial Intelligence Laboratory, Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - David W. M. Muller
- Department of Cardiology, St Vincent’s Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - David A. Roy
- Department of Cardiology, St Vincent’s Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Andrew K. Roy
- Department of Cardiology, St Vincent’s Hospital, Sydney, NSW, Australia
| | - Jason C. Kovacic
- Department of Cardiology, St Vincent’s Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Vascular Biology Laboratory, Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
- Icahn School of Medicine at Mount Sinai, Cardiovascular Research Institute, New York, NY, United States
| | - Christopher S. Hayward
- Department of Cardiology, St Vincent’s Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Cardiac Mechanics Laboratory, Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - Michael P. Feneley
- Department of Cardiology, St Vincent’s Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Cardiac Mechanics Laboratory, Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
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11
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Chowdhury G, Carland JE, Kumar S, Olsen N, Graham G, Kumarasinghe G, Hayward CS, Greenfield JR, Macdonald P, Day RO, Stocker SL. The safe use of metformin in heart failure patients both with and without T2DM: a cross-sectional and longitudinal study. Br J Clin Pharmacol 2023. [PMID: 37016750 DOI: 10.1111/bcp.15737] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/21/2023] [Accepted: 03/25/2023] [Indexed: 04/06/2023] Open
Abstract
AIMS This study investigated the safe use of metformin in patients with (1) type 2 diabetes mellitus (T2DM) and heart failure on metformin, and (2) heart failure without T2DM and metformin naïve. METHODS Two prospective studies on heart failure patients were undertaken. The first was a cross-sectional study with two patient cohorts, one with T2DM on metformin (n=44) and one without T2DM metformin naive (n=47). The second was a 12-week interventional study of patients without T2DM (n=27) where metformin (500 mg immediate release, twice daily) was prescribed. Plasma metformin and lactate concentrations were monitored. Individual pharmacokinetics were compared between cohorts. Univariable and multivariable analysis analysed the effects of variables on plasma lactate concentrations. RESULTS Plasma metformin and lactate concentrations mostly (99.9%) remained below safety thresholds (5 mg/L and 5 mmol/L, respectively). Metformin concentration had no significant relationship with lactic acidosis safety markers. In the interventional study, New York Heart Association (NYHA) II (p<0.03) and III (p<0.001) grading was associated with higher plasma lactate concentrations, whereas male sex was associated with 47% higher plasma lactate concentrations (p<0.05). The pharmacokinetics of heart failure patients with and without T2DM were similar. CONCLUSIONS We observed no unsafe plasma lactate concentrations in patients with heart failure treated with metformin. Metformin exposure did not influence plasma lactate concentrations; however, NYHA class and sex did. The pharmacokinetics of metformin in heart failure patients are similar irrespective of T2DM. These findings may support the safe use of metformin in heart failure patients with and without T2DM.
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Affiliation(s)
- G Chowdhury
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital Sydney, Sydney, Australia
- School of Medical Science, The University of New South Wales, Sydney, Australia
| | - J E Carland
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital Sydney, Sydney, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, UNSW, Sydney, Australia
| | - S Kumar
- Clinical Pharmacology, Modelling and Simulation, Parexel International, Sydney, Australia
| | - N Olsen
- School of Mathematics and Statistics, The University of New South Wales, Sydney, Australia
| | - G Graham
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital Sydney, Sydney, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, UNSW, Sydney, Australia
| | - G Kumarasinghe
- Heart & Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, Australia
- Victor Chang Cardiac Research Institute, Sydney, Australia
- Department of Cardiology, Liverpool Hospital, Sydney, Australia
| | - C S Hayward
- Heart & Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, Australia
- Victor Chang Cardiac Research Institute, Sydney, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, UNSW, Sydney, Australia
| | - J R Greenfield
- Department of Endocrinology, St Vincent's Hospital Sydney, Sydney, Australia
- Garvan Institute of Medical Research, Sydney, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, UNSW, Sydney, Australia
| | - P Macdonald
- Heart & Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, Australia
- Victor Chang Cardiac Research Institute, Sydney, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, UNSW, Sydney, Australia
| | - R O Day
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital Sydney, Sydney, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, UNSW, Sydney, Australia
| | - S L Stocker
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital Sydney, Sydney, Australia
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, UNSW, Sydney, Australia
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12
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Raven LM, Muir CA, Macdonald PS, Hayward CS, Jabbour A, Greenfield JR. Diabetes medication following heart transplantation: a focus on novel cardioprotective therapies-a joint review from endocrinologists and cardiologists. Acta Diabetol 2023; 60:471-480. [PMID: 36538088 DOI: 10.1007/s00592-022-02018-3] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 12/10/2022] [Indexed: 12/25/2022]
Abstract
There is accumulating evidence that novel glucose-lowering agents infer potent cardiovascular and renal benefits. Therefore, it is imperative to reassess the management of post-transplant diabetes mellitus and consider the role of newer agents. With improved transplant-related survival and high prevalence of post-transplant diabetes, management of long-term complications such as diabetes are increasingly important. There are limited guidelines to assist in choice of appropriate agents after solid organ transplantation. Traditional therapies including insulin and sulfonylureas may still have a role; however, other agents should be considered prior. The evidence of novel glucose-lowering agents in post-transplant care is limited, and most studies have focused on kidney transplant recipients. While there are some parallels between renal and cardiac transplant recipients, the potential cardiovascular benefits, particularly on cardiac fibrosis are unique to cardiac transplantation. The treatment of diabetes, with a focus on additional cardiac and renal benefits, needs to be brought to the forefront of post-transplant care with incorporation of recent evidence outside of transplantation. The role for novel glucose-lowering agents in cardiac transplant recipients will be explored, with a summary of available evidence.
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Affiliation(s)
- Lisa M Raven
- Department of Diabetes and Endocrinology, St Vincent's Hospital, Sydney, Australia.
- Clinical Diabetes, Appetite and Metabolism Laboratory, Garvan Institute of Medical Research, Sydney, Australia.
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia.
| | - Christopher A Muir
- Department of Diabetes and Endocrinology, St Vincent's Hospital, Sydney, Australia
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Peter S Macdonald
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- Department of Heart and Lung Transplantation, St Vincent's Hospital, Sydney, Australia
- Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Christopher S Hayward
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- Department of Heart and Lung Transplantation, St Vincent's Hospital, Sydney, Australia
- Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Andrew Jabbour
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- Department of Heart and Lung Transplantation, St Vincent's Hospital, Sydney, Australia
- Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Jerry R Greenfield
- Department of Diabetes and Endocrinology, St Vincent's Hospital, Sydney, Australia
- Clinical Diabetes, Appetite and Metabolism Laboratory, Garvan Institute of Medical Research, Sydney, Australia
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
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13
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Kessler Iglesias C, Pouliopoulos J, Thomas L, Hayward CS, Jabbour A, Fatkin D. Atrial cardiomyopathy: Current and future imaging methods for assessment of atrial structure and function. Front Cardiovasc Med 2023; 10:1099625. [PMID: 37063965 PMCID: PMC10102662 DOI: 10.3389/fcvm.2023.1099625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/16/2023] [Indexed: 04/03/2023] Open
Abstract
Changes in atrial size and function have historically been considered a surrogate marker of ventricular dysfunction. However, it is now recognized that atrial cardiomyopathy (ACM) may also occur as a primary myocardial disorder. Emerging evidence that ACM is a major risk factor for atrial fibrillation, heart failure, and thromboembolic stroke, has highlighted the significance of this disorder and the need for better assessment of atrial metrics in clinical practice. Key barriers in this regard include a lack of standardized criteria or hierarchy for the diagnosis of ACM and lack of consensus for the most accurate phenotyping methods. In this article we review existing literature on ACM, with a focus on current and future non-invasive imaging methods for detecting abnormalities of atrial structure and function. We discuss the relative advantages and disadvantages of transthoracic echocardiography and cardiac magnetic resonance imaging for assessing a range of parameters, including atrial size and contractile function, strain, tissue characteristics, and epicardial adipose tissue. We will also present the potential application of novel imaging methods such as sphericity index and four- or five-dimensional flow.
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Affiliation(s)
- Cassia Kessler Iglesias
- Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia
- Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Jim Pouliopoulos
- Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia
- Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Liza Thomas
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
- Department of Cardiology Westmead Hospital, Sydney, NSW, Australia
- South West Clinical School, UNSW Sydney, Sydney, NSW, Australia
| | - Christopher S. Hayward
- Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia
- Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Andrew Jabbour
- Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia
- Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Diane Fatkin
- Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia
- Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Correspondence: Diane Fatkin
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14
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Raven LM, Muir CA, Kessler Iglesias C, Bart NK, Muthiah K, Kotlyar E, Macdonald P, Hayward CS, Jabbour A, Greenfield JR. Sodium glucose co-transporter 2 inhibition with empagliflozin on metabolic, cardiac and renal outcomes in recent cardiac transplant recipients (EMPA-HTx): protocol for a randomised controlled trial. BMJ Open 2023; 13:e069641. [PMID: 36990488 PMCID: PMC10069602 DOI: 10.1136/bmjopen-2022-069641] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
Abstract
INTRODUCTION Cardiac transplantation (CTx) is a life-saving operation that can improve the quality and length of a recipient's life. Immunosuppression medication, required to prevent rejection, can result in adverse metabolic and renal effects. Clinically significant complications include metabolic effects such as diabetes and weight gain, renal impairment, and cardiac disease such as allograft vasculopathy and myocardial fibrosis. Sodium glucose co-transporter 2 (SGLT2) inhibitors are a class of oral medication that increase urinary excretion of glucose. In patients with type 2 diabetes, SGLT2 inhibitors improve cardiovascular, metabolic and renal outcomes. Similar benefits have been shown in patients with heart failure and reduced ejection fraction irrespective of diabetes status. In patients with post-transplant diabetes mellitus, SGLT2 inhibitors improve metabolic parameters; however, their benefit and safety have not been evaluated in randomised prospective studies. This study will potentially provide a novel therapy to improve or prevent complications (diabetes, kidney failure and heart fibrosis) that occur with immunosuppressive medications. METHODS The EMPA-HTx study is a randomised, placebo-controlled trial of the SGLT2 inhibitor empagliflozin 10 mg daily versus placebo in recent CTx recipients. One hundred participants will be randomised 1:1 and commence the study medication within 6-8 weeks of transplantation with treatment and follow-up until 12 months after transplantation. Demographic information, anthropomorphic measurements, pathology tests and cardiac magnetic resonance (CMR) scan will be recorded at baseline and follow-up. Patients will be reviewed monthly during the study until 12 months post-CTx and data will be collected for each patient at each study visit. The overall aim of the study is to assess the safety and efficacy of empagliflozin in CTx recipients. The primary outcome is glycaemic improvement measured as change in glycated haemoglobin and/or fructosamine. Key secondary outcomes are cardiac interstitial fibrosis measured by CMR and renal function measured by estimated glomerular filtration rate. ETHICS AND DISSEMINATION This study has been approved by St Vincent's Hospital Human Research Ethics Committee (2021/ETH12184). The findings will be presented at national and international scientific meetings and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ACTRN12622000978763.
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Affiliation(s)
- Lisa Mary Raven
- Department of Diabetes and Endocrinology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Clinical Diabetes, Appetite and Metabolism Laboratory, Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Christopher A Muir
- Department of Diabetes and Endocrinology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Cassia Kessler Iglesias
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Heart and Lung Transplantation, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Nicole K Bart
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Heart and Lung Transplantation, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Kavitha Muthiah
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Heart and Lung Transplantation, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Eugene Kotlyar
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Heart and Lung Transplantation, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Peter Macdonald
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Heart and Lung Transplantation, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Christopher S Hayward
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Heart and Lung Transplantation, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Andrew Jabbour
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Heart and Lung Transplantation, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Jerry R Greenfield
- Department of Diabetes and Endocrinology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Clinical Diabetes, Appetite and Metabolism Laboratory, Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
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15
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Namasivayam M, Meredith T, Muller DW, Roy DA, Roy AK, Kovacic JC, Hayward CS, Feneley MP. MACHINE LEARNING PREDICTION OF PROGRESSIVE SUBCLINICAL MYOCARDIAL DYSFUNCTION IN MODERATE AORTIC STENOSIS. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01842-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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16
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Hungerford SL, Dahle G, Duncan A, Hayward CS, Muller DWM. Peri‐procedural management of transcatheter mitral valve replacement in patients with heart failure. Eur J Heart Fail 2022. [DOI: 10.1002/ejhf.2758] [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: 08/27/2022] [Revised: 11/28/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Affiliation(s)
- Sara L Hungerford
- St Vincent's Hospital Clinical School, Faculty of Medicine University of New South Wales Sydney Australia
- Department of Cardiology Royal North Shore Hospital Sydney Australia
| | - Gry Dahle
- Department of Cardiothoracic Surgery Oslo University Hospital Oslo Norway
- Oslo University Oslo Norway
| | - Alison Duncan
- Department of Cardiology Royal Brompton Hospital London United Kingdom
| | - Christopher S Hayward
- St Vincent's Hospital Clinical School, Faculty of Medicine University of New South Wales Sydney Australia
- Department of Cardiology St Vincent's Hospital Sydney Australia
| | - David WM Muller
- St Vincent's Hospital Clinical School, Faculty of Medicine University of New South Wales Sydney Australia
- Department of Cardiology St Vincent's Hospital Sydney Australia
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17
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Adji A, Shehab S, Jain P, Robson D, Jansz P, Hayward CS. Arterial Compliance and Continuous-Flow Left Ventricular Assist Device Pump Function. ASAIO J 2022; 68:925-931. [PMID: 35544445 DOI: 10.1097/mat.0000000000001768] [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: 11/25/2022] Open
Abstract
Durable continuous-flow left ventricular assist devices (cfLVADs) demonstrate superior survival, cardiac functional status, and overall quality of life compared to medical therapy alone in advanced heart failure. Previous studies have not considered the impact arterial compliance may have on pump performance or developed arterial pressure. This study assessed the impact of alterations in arterial compliance, preload, and afterload on continuous-flow pump function and measured hemodynamics using an in-vitro pulsatile mock circulatory loop. Decreased arterial compliance was associated with a significant increase in arterial pressure pulsatility which was not evident in the flow pulsatility, as displayed in pump flow waveforms. There were marked changes in the pump flow waveforms due to the significant alteration in the aortoventricular gradient during diastole according to the changes in compliance. This study demonstrates that changes in systemic blood pressure, afterload, and left ventricular contractility each significantly affects the flow waveform. The association of hypertension with lower aortic compliance results in markedly decreased diastolic flow rates which may be important in contributing to a greater risk of adverse events under cfLVAD support.
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Affiliation(s)
- Audrey Adji
- From the Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
- Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
- St Vincent's Clinical School, UNSW Medicine and Health, Sydney, Australia
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Sajad Shehab
- Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Pankaj Jain
- From the Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
| | - Desiree Robson
- From the Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
| | - Paul Jansz
- From the Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
- Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
- St Vincent's Clinical School, UNSW Medicine and Health, Sydney, Australia
- School of Medicine, University of Notre Dame, Sydney, Australia
| | - Christopher S Hayward
- From the Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
- Mechanical Circulatory Support Laboratory, Victor Chang Cardiac Research Institute, Sydney, Australia
- St Vincent's Clinical School, UNSW Medicine and Health, Sydney, Australia
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18
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Anthony C, Imran M, Pouliopoulos J, Emmanuel S, Iliff J, Liu Z, Moffat K, Ru Qiu M, McLean CA, Stehning C, Puntmann V, Vassiliou V, Ismail TF, Gulati A, Prasad S, Graham RM, McCrohon J, Holloway C, Kotlyar E, Muthiah K, Keogh AM, Hayward CS, Macdonald PS, Jabbour A. Cardiovascular Magnetic Resonance for Rejection Surveillance After Cardiac Transplantation. Circulation 2022; 145:1811-1824. [PMID: 35621277 DOI: 10.1161/circulationaha.121.057006] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND Endomyocardial biopsy (EMB) is the gold standard method for surveillance of acute cardiac allograft rejection (ACAR) despite its invasive nature. Cardiovascular magnetic resonance (CMR)-based myocardial tissue characterization allows detection of myocarditis. The feasibility of CMR-based surveillance for ACAR-induced myocarditis in the first year after heart transplantation is currently undescribed. METHODS CMR-based multiparametric mapping was initially assessed in a prospective cross-sectional fashion to establish agreement between CMR- and EMB-based ACAR and to determine CMR cutoff values between rejection grades. A prospective randomized noninferiority pilot study was then undertaken in adult orthotopic heart transplant recipients who were randomized at 4 weeks after orthotopic heart transplantation to either CMR- or EMB-based rejection surveillance. Clinical end points were assessed at 52 weeks. RESULTS Four hundred one CMR studies and 354 EMB procedures were performed in 106 participants. Forty heart transplant recipients were randomized. CMR-based multiparametric assessment was highly reproducible and reliable at detecting ACAR (area under the curve, 0.92; sensitivity, 93%; specificity, 92%; negative predictive value, 99%) with greater specificity and negative predictive value than either T1 or T2 parametric CMR mapping alone. High-grade rejection occurred in similar numbers of patients in each randomized group (CMR, n=7; EMB, n=8; P=0.74). Despite similarities in immunosuppression requirements, kidney function, and mortality between groups, the rates of hospitalization (9 of 20 [45%] versus 18 of 20 [90%]; odds ratio, 0.091; P=0.006) and infection (7 of 20 [35%] versus 14 of 20 [70%]; odds ratio, 0.192; P=0,019) were lower in the CMR group. On 15 occasions (6%), patients who were randomized to the CMR arm underwent EMB for clarification or logistic reasons, representing a 94% reduction in the requirement for EMB-based surveillance. CONCLUSIONS A noninvasive CMR-based surveillance strategy for ACAR in the first year after orthotopic heart transplantation is feasible compared with EMB-based surveillance. REGISTRATION HREC/13/SVH/66 and HREC/17/SVH/80. AUSTRALIAN NEW ZEALAND CLINICAL TRIALS REGISTRY ACTRN12618000672257.
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Affiliation(s)
- Chris Anthony
- Heart and Lung Transplant Unit (C.A., M.I., J.P., S.E., J.I., M.R.Q., R.M.G., J.M., C.H., E.K., K.M., A.M.K., C.S.H., P.S.M., A.J.), St. Vincent's Hospital, Sydney, Australia
| | - Muhammad Imran
- Heart and Lung Transplant Unit (C.A., M.I., J.P., S.E., J.I., M.R.Q., R.M.G., J.M., C.H., E.K., K.M., A.M.K., C.S.H., P.S.M., A.J.), St. Vincent's Hospital, Sydney, Australia
| | - Jim Pouliopoulos
- Heart and Lung Transplant Unit (C.A., M.I., J.P., S.E., J.I., M.R.Q., R.M.G., J.M., C.H., E.K., K.M., A.M.K., C.S.H., P.S.M., A.J.), St. Vincent's Hospital, Sydney, Australia.,Medical Imaging Department (K.M.), St. Vincent's Hospital, Sydney, Australia.,UNSW, Sydney, Australia (J.P., R.M.G., A.M.K., P.S.M., A.J.)
| | - Sam Emmanuel
- Heart and Lung Transplant Unit (C.A., M.I., J.P., S.E., J.I., M.R.Q., R.M.G., J.M., C.H., E.K., K.M., A.M.K., C.S.H., P.S.M., A.J.), St. Vincent's Hospital, Sydney, Australia.,Medical Imaging Department (K.M.), St. Vincent's Hospital, Sydney, Australia
| | - James Iliff
- Heart and Lung Transplant Unit (C.A., M.I., J.P., S.E., J.I., M.R.Q., R.M.G., J.M., C.H., E.K., K.M., A.M.K., C.S.H., P.S.M., A.J.), St. Vincent's Hospital, Sydney, Australia
| | - Zhixin Liu
- Stats Central, Mark Wainwright Analytical Centre, UNSW, Sydney, Australia (Z.L.)
| | - Kirsten Moffat
- Heart and Lung Transplant Unit (C.A., M.I., J.P., S.E., J.I., M.R.Q., R.M.G., J.M., C.H., E.K., K.M., A.M.K., C.S.H., P.S.M., A.J.), St. Vincent's Hospital, Sydney, Australia.,Medical Imaging Department (K.M.), St. Vincent's Hospital, Sydney, Australia
| | - Min Ru Qiu
- Heart and Lung Transplant Unit (C.A., M.I., J.P., S.E., J.I., M.R.Q., R.M.G., J.M., C.H., E.K., K.M., A.M.K., C.S.H., P.S.M., A.J.), St. Vincent's Hospital, Sydney, Australia
| | | | | | - Valentina Puntmann
- Institute for Experimental and Translational Cardiovascular Imaging, Goethe University Hospital, Frankfurt, Germany (V.P.)
| | - Vass Vassiliou
- CMR, Royal Brompton Hospital, Imperial College London, UK (V.V., A.G., S.P.).,Norwich Medical School, University of East Anglia, UK (V.V.)
| | | | - Ankur Gulati
- CMR, Royal Brompton Hospital, Imperial College London, UK (V.V., A.G., S.P.)
| | - Sanjay Prasad
- CMR, Royal Brompton Hospital, Imperial College London, UK (V.V., A.G., S.P.)
| | - Robert M Graham
- Heart and Lung Transplant Unit (C.A., M.I., J.P., S.E., J.I., M.R.Q., R.M.G., J.M., C.H., E.K., K.M., A.M.K., C.S.H., P.S.M., A.J.), St. Vincent's Hospital, Sydney, Australia.,Medical Imaging Department (K.M.), St. Vincent's Hospital, Sydney, Australia.,UNSW, Sydney, Australia (J.P., R.M.G., A.M.K., P.S.M., A.J.)
| | - Jane McCrohon
- Heart and Lung Transplant Unit (C.A., M.I., J.P., S.E., J.I., M.R.Q., R.M.G., J.M., C.H., E.K., K.M., A.M.K., C.S.H., P.S.M., A.J.), St. Vincent's Hospital, Sydney, Australia
| | - Cameron Holloway
- Heart and Lung Transplant Unit (C.A., M.I., J.P., S.E., J.I., M.R.Q., R.M.G., J.M., C.H., E.K., K.M., A.M.K., C.S.H., P.S.M., A.J.), St. Vincent's Hospital, Sydney, Australia
| | - Eugene Kotlyar
- Heart and Lung Transplant Unit (C.A., M.I., J.P., S.E., J.I., M.R.Q., R.M.G., J.M., C.H., E.K., K.M., A.M.K., C.S.H., P.S.M., A.J.), St. Vincent's Hospital, Sydney, Australia
| | - Kavitha Muthiah
- Heart and Lung Transplant Unit (C.A., M.I., J.P., S.E., J.I., M.R.Q., R.M.G., J.M., C.H., E.K., K.M., A.M.K., C.S.H., P.S.M., A.J.), St. Vincent's Hospital, Sydney, Australia
| | - Anne M Keogh
- Heart and Lung Transplant Unit (C.A., M.I., J.P., S.E., J.I., M.R.Q., R.M.G., J.M., C.H., E.K., K.M., A.M.K., C.S.H., P.S.M., A.J.), St. Vincent's Hospital, Sydney, Australia.,UNSW, Sydney, Australia (J.P., R.M.G., A.M.K., P.S.M., A.J.)
| | - Christopher S Hayward
- Heart and Lung Transplant Unit (C.A., M.I., J.P., S.E., J.I., M.R.Q., R.M.G., J.M., C.H., E.K., K.M., A.M.K., C.S.H., P.S.M., A.J.), St. Vincent's Hospital, Sydney, Australia.,Victor Chang Cardiac Research Institute, Sydney, Australia (J.P., S.E., R.M.G., C.S.H., P.S.M., A.J.)
| | - Peter S Macdonald
- Heart and Lung Transplant Unit (C.A., M.I., J.P., S.E., J.I., M.R.Q., R.M.G., J.M., C.H., E.K., K.M., A.M.K., C.S.H., P.S.M., A.J.), St. Vincent's Hospital, Sydney, Australia.,Victor Chang Cardiac Research Institute, Sydney, Australia (J.P., S.E., R.M.G., C.S.H., P.S.M., A.J.).,UNSW, Sydney, Australia (J.P., R.M.G., A.M.K., P.S.M., A.J.)
| | - Andrew Jabbour
- Heart and Lung Transplant Unit (C.A., M.I., J.P., S.E., J.I., M.R.Q., R.M.G., J.M., C.H., E.K., K.M., A.M.K., C.S.H., P.S.M., A.J.), St. Vincent's Hospital, Sydney, Australia.,Victor Chang Cardiac Research Institute, Sydney, Australia (J.P., S.E., R.M.G., C.S.H., P.S.M., A.J.).,UNSW, Sydney, Australia (J.P., R.M.G., A.M.K., P.S.M., A.J.)
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19
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Deveza RC, Doyle MP, Schnegg B, Pearman M, Emmanuel S, Goh SSC, Robson D, Muthiah K, Watson A, Hayward CS. Intermittent Papillary Muscle Suction: A Rare Cause of Left Ventricular Assist Device Low Flow. JACC Case Rep 2021; 3:1680-1684. [PMID: 34766018 PMCID: PMC8571786 DOI: 10.1016/j.jaccas.2021.07.025] [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: 05/06/2021] [Revised: 07/22/2021] [Accepted: 07/27/2021] [Indexed: 12/02/2022]
Abstract
Low flow alarms represent a management challenge in patients with left ventricular assist devices because they are often a consequence of complex patient-device interactions. We present a case of intermittent suction of the postero-medial papillary muscle into the left ventricular assist device inflow cannula during diastole, causing low flows. This case highlights the importance of a systematic approach and use of multiple investigation modalities in making an accurate diagnosis. (Level of Difficulty: Advanced.).
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Affiliation(s)
| | - Mathew P. Doyle
- Department of Cardiothoracic Surgery, St Vincent’s Hospital, Sydney, Australia
| | - Bruno Schnegg
- Department of Cardiology, St Vincent’s Hospital, Sydney, Australia
| | | | - Sam Emmanuel
- Department of Cardiothoracic Surgery, St Vincent’s Hospital, Sydney, Australia
- School of Medicine, University of Notre Dame, Sydney, Australia
| | - Siew SC. Goh
- Department of Cardiothoracic Surgery, St Vincent’s Hospital, Sydney, Australia
| | - Desiree Robson
- Department of Cardiology, St Vincent’s Hospital, Sydney, Australia
| | - Kavitha Muthiah
- Department of Cardiology, St Vincent’s Hospital, Sydney, Australia
| | - Alasdair Watson
- Department of Cardiothoracic Surgery, St Vincent’s Hospital, Sydney, Australia
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20
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Hungerford SL, Adji AI, Hayward CS, Muller DWM. Ageing, Hypertension and Aortic Valve Stenosis: A Conscious Uncoupling. Heart Lung Circ 2021; 30:1627-1636. [PMID: 34274230 DOI: 10.1016/j.hlc.2021.05.108] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/17/2021] [Accepted: 05/18/2021] [Indexed: 10/20/2022]
Abstract
Aortic valve stenosis (AS) is no longer considered to be a disease of fixed left ventricular (LV) afterload (due to an obstructive valve), but rather, functions as a series circuit with important contributions from both the valve and ageing vasculature. Patients with AS are frequently elderly, with hypertension and a markedly remodelled aorta. The arterial component is sizable, and yet, the contribution of ventricular afterload has been difficult to determine. Arterial stiffening increases the speed of propagation of the blood pressure wave along the central arteries (estimated as the pulse wave velocity), which results in an earlier return of reflected waves. The effect is to augment blood pressure in the proximal aorta during systole, increasing the central pulse pressure and, in turn, placing even greater afterload on the heart. Elevated global LV afterload is known to have adverse consequences on LV remodelling, function and survival in patients with AS. Consequently, there is renewed focus on methods to estimate the relative contributions of local versus global changes in arterial mechanics and valvular haemodynamics in patients with AS. We present a review on existing and upcoming methods to quantify valvulo-arterial impedance and thereby global LV load in patients with AS.
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Affiliation(s)
- Sara L Hungerford
- Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia; The University of New South Wales, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia.
| | - Audrey I Adji
- Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia; The University of New South Wales, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia; Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Christopher S Hayward
- Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia; The University of New South Wales, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - David W M Muller
- Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia; The University of New South Wales, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
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21
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Rao SD, Connor DE, Shehab S, Kerr NP, Joseph J, Muthiah K, Jain P, Robson D, Jansz P, Hayward CS. Ex Vivo Assessment of Different Oral Anticoagulant Regimens on Pump Thrombosis in a HeartWare Ventricular Assist Device. Circ Heart Fail 2021; 14:e007231. [PMID: 34210157 DOI: 10.1161/circheartfailure.120.007231] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND In light of decreased intracranial hemorrhage with direct oral anticoagulants and concerns about their safety in continuous flow left ventricular assist devices, we conducted an ex vivo study of thrombus formation using multiple anticoagulation agents. METHODS A continuous flow left ventricular assist device (HeartWare ventricular assist device) hemocompatibility loop was run using human blood under 7 conditions: control (no anticoagulation or antiplatelet); in vitro addition of aspirin; in vitro addition of apixaban at low dose (equivalent 2.5 mg twice daily); addition of apixaban at high dose (equivalent 5 mg twice daily); patients on warfarin; patients on apixaban (5 mg twice daily); and patients on dabigatran (150 mg twice daily). The primary outcome was time to formation of intrapump thrombosis. Secondary outcomes were reduction in clotting times over 1 hour, hemolysis, reduced platelet aggregation, and von Willebrand activity. RESULTS Twenty-one runs were completed. Times to thrombosis in median (interquartile range) were control, 131 (127-134.5); in vitro aspirin, 124 (114.5-137); and patients on dabigatran, 131 (130.5-135.5) minutes, respectively. Times in patients on warfarin were, 137 (136.5-143.5); in vitro low-dose apixaban, 141 (138.5-142); and patients on apixaban, 140 (138-142.5) minutes, respectively. No thrombus formed in the in vitro high-dose apixaban group. There were no significant differences between the individual groups. When all apixaban groups were compared with nonapixaban groups, the time to thrombosis formation was significantly longer, 143 (137-150) versus 133.5 (128.5-140) minutes, P=0.02. There were similar changes in lactate dehydrogenase levels and other secondary end points. CONCLUSIONS In an in vitro study of anticoagulation using human blood in a mock loop with a HeartWare HVAD, we demonstrated similar thrombosis times for apixaban and warfarin. Time to clotting was longer in the combined apixaban groups compared with combined other groups, but thrombosis times between individual groups were not significantly different.
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Affiliation(s)
- Sriram D Rao
- Advanced Heart Failure/Transplantation Program, MedStar Washington Hospital Center, Washington DC (S.D.R.).,University of New South Wales, Sydney, NSW, Australia (S.D.R., N.P.K., K.M., P.J., C.S.H.).,Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia (S.D.R., S.S., N.P.K., K.M., P.J., C.S.H.)
| | - David E Connor
- Department of Hematology, St. Vincent's Hospital, Sydney, NSW, Australia (D.E.C., J.J.)
| | - Sajad Shehab
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia (S.D.R., S.S., N.P.K., K.M., P.J., C.S.H.)
| | - Nicholas P Kerr
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Darlinghurst, NSW, Australia (N.P.K., K.M., P.J., D.R., P.J., C.S.H.).,University of New South Wales, Sydney, NSW, Australia (S.D.R., N.P.K., K.M., P.J., C.S.H.).,Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia (S.D.R., S.S., N.P.K., K.M., P.J., C.S.H.)
| | - Joanne Joseph
- Department of Hematology, St. Vincent's Hospital, Sydney, NSW, Australia (D.E.C., J.J.)
| | - Kavitha Muthiah
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Darlinghurst, NSW, Australia (N.P.K., K.M., P.J., D.R., P.J., C.S.H.).,University of New South Wales, Sydney, NSW, Australia (S.D.R., N.P.K., K.M., P.J., C.S.H.)
| | - Pankaj Jain
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Darlinghurst, NSW, Australia (N.P.K., K.M., P.J., D.R., P.J., C.S.H.)
| | - Desiree Robson
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Darlinghurst, NSW, Australia (N.P.K., K.M., P.J., D.R., P.J., C.S.H.)
| | - Paul Jansz
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Darlinghurst, NSW, Australia (N.P.K., K.M., P.J., D.R., P.J., C.S.H.).,University of New South Wales, Sydney, NSW, Australia (S.D.R., N.P.K., K.M., P.J., C.S.H.).,Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia (S.D.R., S.S., N.P.K., K.M., P.J., C.S.H.)
| | - Christopher S Hayward
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Darlinghurst, NSW, Australia (N.P.K., K.M., P.J., D.R., P.J., C.S.H.).,University of New South Wales, Sydney, NSW, Australia (S.D.R., N.P.K., K.M., P.J., C.S.H.).,Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia (S.D.R., S.S., N.P.K., K.M., P.J., C.S.H.)
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22
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Anthony C, Imran M, Pouliopoulos J, Emmanuel S, Iliff JW, Moffat KJ, Ross J, Graham RM, Kotlyar E, Muthiah K, Keogh AM, Hayward CS, Macdonald P, Jabbour A. Everolimus for the Prevention of Calcineurin-Inhibitor-Induced Left Ventricular Hypertrophy After Heart Transplantation (RADTAC Study). JACC Heart Fail 2021; 9:301-313. [PMID: 33795116 DOI: 10.1016/j.jchf.2021.01.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 01/04/2021] [Accepted: 01/24/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study aimed to determine the safety and efficacy of combined low-dose everolimus and low-dose tacrolimus compared with standard-dose tacrolimus in attenuating left ventricular hypertrophy (LVH) after orthotopic heart transplantation (OHT). BACKGROUND Calcineurin inhibitors (CNIs) such as tactrolimus are important in preventing cardiac allograft rejection and reducing mortality after OHT. However CNIs are causatively linked to the development of LVH, and are associated with nephrotoxicity and vasculopathy. CNI-sparing agents such as everolimus have been hypothesized to inhibit adverse effects of CNIs. METHODS In this prospective, randomized, open-label study, OHT recipients were randomized at 12 weeks after OHT to a combination of low-dose everolimus and tacrolimus (the RADTAC group) or standard-dose tacrolimus (the TAC group), with both groups coadministered mycophenolate and prednisolone. The primary endpoint was LVH indexed as the change in left ventricular mass (ΔLVM) by cardiovascular magnetic resonance (CMR) imaging from 12 to 52 weeks. Secondary endpoints included CMR-based myocardial performance, T1 fibrosis mapping, blood pressure, and renal function. Safety endpoints included episodes of allograft rejection and infection. RESULTS Forty stable OHT recipients were randomized. Recipients in the RADTAC group had significantly lower tacrolimus levels compared with the TAC group (6.5 ± 3.5 μg/l vs. 8.6 ± 2.8 μg/l; p = 0.02). The mean everolimus level in the RADTAC group was 4.2 ± 1.7 μg/l. A significant reduction in LVM was observed in the RADTAC group compared with an increase in LVM in the TAC group (ΔLVM = -13.0 ± 16.8 g vs. 2.1 ± 8.4 g; p < 0.001). Significant differences were also noted in secondary endpoints measuring function and fibrosis (Δ circumferential strain = -2.9 ± 2.8 vs. 2.1 ± 2.3; p < 0.001; ΔT1 mapping values = -32.7 ± 51.3 ms vs. 26.3 ± 90.4 ms; p = 0.003). No significant differences were observed in blood pressure (Δ mean arterial pressure = 4.2 ± 18.8 mm Hg vs. 2.8 ± 13.8 mm Hg; p = 0.77), renal function (Δ creatinine = 3.1 ± 19.9 μmol/l vs. 9 ± 21.8 μmol/l; p = 0.31), frequency of rejection episodes (p = 0.69), or frequency of infections (p = 0.67) between groups. CONCLUSIONS The combination of low-dose everolimus and tacrolimus compared with standard-dose tacrolimus safely attenuates LVH in the first year after cardiac transplantation with an observed reduction in CMR-measured fibrosis and an improvement in myocardial strain.
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Affiliation(s)
- Chris Anthony
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia
| | - Muhammad Imran
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia
| | - Jim Pouliopoulos
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia; Victor Chang Cardiac Research Institute
| | - Sam Emmanuel
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia
| | - James W Iliff
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia
| | - Kirsten J Moffat
- Medical Imaging Department, St. Vincent's Hospital, Sydney, Australia
| | - Joanne Ross
- Medical Imaging Department, St. Vincent's Hospital, Sydney, Australia
| | - Robert M Graham
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia; Victor Chang Cardiac Research Institute; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Eugene Kotlyar
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Kavitha Muthiah
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Anne M Keogh
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Christopher S Hayward
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia; Victor Chang Cardiac Research Institute; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Peter Macdonald
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia; Victor Chang Cardiac Research Institute; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew Jabbour
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia; Victor Chang Cardiac Research Institute; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
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23
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Jain P, Meredith T, Adji A, Schnegg B, Hayward CS. Spontaneous Oscillatory Left Ventricular-Aortic Uncoupling Under Continuous-Flow Left Ventricular Assist Device Support. Circ Heart Fail 2021; 14:e007658. [PMID: 33504157 DOI: 10.1161/circheartfailure.120.007658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Pankaj Jain
- Heart Failure and Transplant Unit, St Vincent's Hospital, Sydney, Australia (P.J., T.M., A.A., B.S., C.S.H.).,Faculty of Medicine, University of New South Wales, Sydney, Australia (P.J., C.S.H.)
| | - Thomas Meredith
- Heart Failure and Transplant Unit, St Vincent's Hospital, Sydney, Australia (P.J., T.M., A.A., B.S., C.S.H.)
| | - Audrey Adji
- Heart Failure and Transplant Unit, St Vincent's Hospital, Sydney, Australia (P.J., T.M., A.A., B.S., C.S.H.)
| | - Bruno Schnegg
- Heart Failure and Transplant Unit, St Vincent's Hospital, Sydney, Australia (P.J., T.M., A.A., B.S., C.S.H.)
| | - Christopher S Hayward
- Heart Failure and Transplant Unit, St Vincent's Hospital, Sydney, Australia (P.J., T.M., A.A., B.S., C.S.H.).,Faculty of Medicine, University of New South Wales, Sydney, Australia (P.J., C.S.H.).,Victor Chang Cardiac Research Institute, Sydney, Australia (C.S.H.)
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24
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Jain P, Adji A, Emmanuel S, Robson D, Muthiah K, Macdonald PS, Hayward CS. Phenotyping of Stable Left Ventricular Assist Device Patients Using Noninvasive Pump Flow Responses to Acute Loading Transients. J Card Fail 2021; 27:642-650. [PMID: 33497807 DOI: 10.1016/j.cardfail.2021.01.009] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 01/10/2021] [Accepted: 01/11/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although it has been established that continuous flow left ventricular assist devices are sensitive to loading conditions, the effect of acute load and postural changes on pump flow have not been explored systematically. METHODS AND RESULTS Fifteen stable outpatients were studied. Patients sequentially transitioned from the seated position to supine, passive leg raise, and standing with transition effects documented. A modified Valsalva maneuver, consisting of a forced expiration with an open glottis, was performed in each position. A sustained, 2-handed handgrip was performed in the supine position. The pump flow waveform was recorded continuously and left ventricular end-diastolic diameter measured during each stage using transthoracic echocardiography. Transitioning from seated to supine posture produced a significant increase in the flow and the ventricular end-diastolic diameter, consistent with an increased preload. The transition from supine to standing produced a transient increase in the mean flow and decreased the flow pulsatility index. At steady state, these changes were reversed with a decrease in the mean and trough flow and increased pulsatility index, consistent with venous redistribution and possible baroreflex compensation. Four distinct patterns of standing-induced flow waveform effects were identified, reflecting varying preload, afterload, and individual compensatory effects. A sustained handgrip produced a significant decrease in flow and increase in flow pulsatility across all patients, reflecting an increased afterload pressure. A modified Valsalva maneuver produced a decrease in the flow pulsatility while seated, supine, and standing, but not during leg raise. Five patterns of pulsatility effect during Valsalva were observed: (1) minimal change, (2) pulsatility recovery, (3) rapid flatline, (4) slow flatline with delayed flow recovery, and (5) primary suction. CONCLUSIONS Acute disturbances in loading conditions produce heterogeneous pump flow responses reflecting their complex interactions with pump and ventricular function as well as reflex compensatory mechanisms. Differences in responses and individual variabilities have significant implications for automated pump control algorithms.
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Affiliation(s)
- Pankaj Jain
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; University of New South Wales, Sydney, Australia
| | - Audrey Adji
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
| | - Sam Emmanuel
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; University of New South Wales, Sydney, Australia
| | - Desiree Robson
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
| | - Kavitha Muthiah
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia
| | - Peter S Macdonald
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; University of New South Wales, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Christopher S Hayward
- Heart Failure and Transplant Unit, Cardiology Department, St Vincent's Hospital, Sydney, Australia; University of New South Wales, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia.
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25
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Prichard RA, Zhao FL, Mcdonagh J, Goodall S, Davidson PM, Newton PJ, Farr-Wharton B, Hayward CS. Discrepancies between proxy estimates and patient reported, health related, quality of life: minding the gap between patient and clinician perceptions in heart failure. Qual Life Res 2021; 30:1049-1059. [PMID: 33387292 DOI: 10.1007/s11136-020-02722-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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] [Accepted: 11/23/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Health related quality of life (HRQoL) is rarely routinely measured in the clinical setting. In the absence of patient reported data, clinicians rely on proxy and informal estimates to support clinical decisions. This study compares clinician estimates (proxy) with patient reported HRQoL in patients with advanced heart failure and examines factors influencing discrepancies. METHODS Seventy-five patients with heart failure, (22 females, 53 males) completed the EQ-5D-5L questionnaire. Thirty-nine clinicians (11 medical, 23 nursing, 5 allied health) completed the proxy version (V1) producing 194 dyads. Correlation was assessed using Spearman's rank tests, systematic bias was examined with Bland-Altman analyses. Inter-rater agreement at the domain level, was investigated using linear weighted Kappa statistics while factors influencing the IRG were explored using independent student t-tests, analysis of variance and regression. RESULTS There was a moderate positive correlation between clinician HRQoL estimates and patient reported utility (r = 0.38; p < .0005). Mean clinician estimates were higher than patient reported utility (0.60 vs 0.54; p = 0.008), with significant underestimation of reported problems apparent in three of the five EQ-5D-5L domains. Patient sex (female), depressed mood and frailty were all associated with an increased inter-rater gap. CONCLUSION Clinicians in this sample overestimated HRQoL. Factors affecting the inter-rater gap, including sex and depression, support formal HRQoL screening to enhance clinical conversations and decision making. The discrepancy also supports regulatory restriction on the use of expert opinion in the development of QALYs in health economic analysis.
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Affiliation(s)
- Roslyn A Prichard
- Faculty of Health, University of Technology, Ultimo, NSW, Australia.
| | - Fei-Li Zhao
- School of Biomedical Sciences and Pharmacy, The University of Newcastle, Callaghan, Australia
| | - Julee Mcdonagh
- Faculty of Health, University of Technology, Ultimo, NSW, Australia
| | - Stephen Goodall
- Centre for Health Economic Research and Evaluation, University of Technology Sydney, Ultimo, Australia
| | | | - Phillip J Newton
- School of Nursing and Midwifery, Western Sydney University, Parramatta, NSW, Australia
| | - Ben Farr-Wharton
- School of Business and Law, Edith Cowan University, Joondalup, WA, Australia
| | - Christopher S Hayward
- Faculty of Health, University of Technology, Ultimo, NSW, Australia
- Faculty of Medicine, University of New South Wales, Randwick, NSW, Australia
- St Vincent's Hospital Heart and Lung Clinic, St Vincent's Hospital Sydney, Darlinghurst, Australia
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26
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McGiffin DC, Kure CE, Hayward CS, Fraser JF. Ethics and governance is becoming unethical: time for some common sense? ANZ J Surg 2020; 89:1538-1539. [PMID: 31846560 DOI: 10.1111/ans.15447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 08/25/2019] [Indexed: 11/30/2022]
Affiliation(s)
- David C McGiffin
- Cardiothoracic Surgery, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Christina E Kure
- Cardiothoracic Surgery, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Christopher S Hayward
- Heart Lung Clinic, St Vincent's Hospital, Sydney, New South Wales, Australia.,School of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
| | - John F Fraser
- Critical Care Research Group, The University of Queensland, Brisbane, Queensland, Australia.,Adult Intensive Care Department, The Prince Charles Hospital, Brisbane, Queensland, Australia
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27
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Allida SM, Shehab S, Inglis SC, Davidson PM, Hayward CS, Newton PJ. A RandomisEd ControLled TrIal of ChEwing Gum to RelieVE Thirst in Chronic Heart Failure (RELIEVE-CHF). Heart Lung Circ 2020; 30:516-524. [PMID: 33032897 DOI: 10.1016/j.hlc.2020.09.004] [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] [Received: 12/27/2018] [Revised: 01/22/2020] [Accepted: 09/13/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Thirst is a common and troublesome symptom of patients with chronic heart failure (CHF). To date, there are no interventions to help alleviate thirst in this cohort. Chewing gum is a novel intervention, which has been tested in people undergoing haemodialysis, also prescribed with a fluid restricted therapy. The aim of this study was to determine the effect of chewing gum on the level of thirst in the short-term (average of 24 hours each day for 4 days) and in the longer-term (Days 7, 14 and 28) individuals with CHF. METHODS Seventy-one (71) individuals with CHF on oral loop diuretics were randomised to chewing gum (n=36) or control (n=35) for 2 weeks. Both groups were assessed for their level of thirst at Days 1-4, 7, 14 and 28. RESULTS Significant improvements in the level of thirst of those who received chewing gum compared to the control group at Day 4 (p=0.04) and Day 14 (p=0.02) were observed. CONCLUSION Chewing gum provided relief from thirst in the short-term and in the longer term. This trial provides important information to inform future clinical trials on ways to relieve thirst.
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Affiliation(s)
- Sabine M Allida
- Neurological and Mental Health Division, The George Institute for Global Health, Sydney, NSW, Australia; IMPACCT Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.
| | - Sajad Shehab
- Cardiac Diagnostic Service, Blacktown Hospital, Sydney, NSW, Australia
| | - Sally C Inglis
- IMPACCT Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | | | | | - Phillip J Newton
- Nursing Research Centre, Western Sydney University, Sydney, NSW, Australia
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28
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Affiliation(s)
- Pankaj Jain
- Department of Cardiology, St Vincent's Hospital, Sydney, Australia
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29
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Marasco S, Simon AR, Tsui S, Schramm R, Eifert S, Hagl CM, Paç M, Kervan Ü, Fiane AE, Wagner FM, Garbade J, Özbaran M, Hayward CS, Zimpfer D, Schmitto JD. International experience using a durable, centrifugal-flow ventricular assist device for biventricular support. J Heart Lung Transplant 2020; 39:1372-1379. [PMID: 32917479 DOI: 10.1016/j.healun.2020.08.006] [Citation(s) in RCA: 10] [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: 04/23/2020] [Revised: 08/10/2020] [Accepted: 08/17/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Heart transplantation is limited by the scarcity of suitable donors. Patients with advanced biventricular failure may require biventricular support to provide optimal cardiac output and end-organ perfusion. We highlight the outcomes of using the HeartWare HVAD System (HVAD) in a biventricular configuration. METHODS This retrospective study included patients implanted with HVAD as a biventricular assist device (BiVAD) between 2009 and 2017 at 12 participating centers. When used as a right ventricular assist device (VAD) (RVAD), the HVAD can be attached to the right ventricle (RV) or the right atrium (RA). Kaplan-Meier survival estimates were calculated comparing the 2 RVAD implant locations. Comparisons were also made between the timing of RVAD implantation (primary vs staged) on adverse event (AE) profiles and survival. RESULTS Among the 93 patients who were implanted with a HVAD BiVAD, Kaplan-Meier survivals at 1-year and 2-year were 56% and 47%, respectively. Survival was independent of the location of the HVAD RVAD implant or whether there was an interval between left VAD and RVAD implantation. The most common AEs were bleeding (35.5%), infection (25.8%), and respiratory failure (20.4%). CONCLUSIONS This study illustrated similar survival in patients receiving a primary or staged HVAD BiVAD implant at 1 year and 2 years. This study also established that the locations of the RVAD implant (RV or RA) result in similar AE profiles.
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Affiliation(s)
- Silvana Marasco
- Cardiothoracic Department, Alfred Hospital, Melbourne, Victoria, Australia.
| | - André R Simon
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield, London, United Kingdom
| | - Steven Tsui
- Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, United Kingdom
| | - René Schramm
- Clinic for Thoracic and Cardiovasuclar Surgery, Heart and Diabetes Center NRW, Bad Oeynhausen, Germany
| | - Sandra Eifert
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Saxony, Germany
| | - Christian M Hagl
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Bavaria, Germany
| | - Mustafa Paç
- Department of Heart Transplantation, Turkey Yüksek İhtisas Education & Research Hospital, Ankara, Turkey
| | - Ümit Kervan
- Department of Heart Transplantation, Turkey Yüksek İhtisas Education & Research Hospital, Ankara, Turkey
| | - Arnt E Fiane
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
| | - Florian M Wagner
- Department of Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Garbade
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Saxony, Germany
| | - Mustafa Özbaran
- Department of Thoracic and Cardiovascular Surgery, Ege Üniversitesi Medical Faculty Hospital, İzmir, Turkey
| | | | - Daniel Zimpfer
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
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30
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Lal S, Hayward CS, De Pasquale C, Kaye D, Javorsky G, Bergin P, Atherton JJ, Ilton MK, Weintraub RG, Nair P, Rudas M, Dembo L, Doughty RN, Kumarasinghe G, Juergens C, Bannon PG, Bart NK, Chow CK, Lattimore JD, Kritharides L, Totaro R, Macdonald PS. COVID-19 and Acute Heart Failure: Screening the Critically Ill - A Position Statement of the Cardiac Society of Australia and New Zealand (CSANZ). Heart Lung Circ 2020; 29:e94-e98. [PMID: 32418875 PMCID: PMC7252099 DOI: 10.1016/j.hlc.2020.04.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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] [Indexed: 01/08/2023]
Abstract
Up to one-third of COVID-19 patients admitted to intensive care develop an acute cardiomyopathy, which may represent myocarditis or stress cardiomyopathy. Further, while mortality in older patients with COVID-19 appears related to multi-organ failure complicating acute respiratory distress syndrome (ARDS), the cause of death in younger patients may be related to acute heart failure. Cardiac involvement needs to be considered early on in critically ill COVID-19 patients, and even after the acute respiratory phase is passing. This Statement presents a screening algorithm to better identify COVID-19 patients at risk for severe heart failure and circulatory collapse, while balancing the need to protect health care workers and preserve personal protective equipment (PPE). The significance of serum troponin levels and the role of telemetry and targeted transthoracic echocardiography (TTE) in patient investigation and management are addressed, as are fundamental considerations in the management of acute heart failure in COVID-19 patients.
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Affiliation(s)
- Sean Lal
- Royal Prince Alfred Hospital, Sydney, NSW, Australia; The University of Sydney, Sydney, NSW, Australia.
| | - Christopher S. Hayward
- St Vincent’s Hospital, Sydney, NSW, Australia,The University of New South Wales, Sydney, NSW, Australia,Corresponding author at:
| | | | - David Kaye
- Alfred Hospital and the Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - George Javorsky
- The Prince Charles Hospital, Brisbane, Qld, Australia,The University of Queensland, Brisbane, Qld, Australia
| | - Peter Bergin
- Alfred Hospital and the Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - John J. Atherton
- The University of Queensland, Brisbane, Qld, Australia,Royal Brisbane and Women’s Hospital, Brisbane, Qld, Australia
| | | | - Robert G. Weintraub
- Royal Children’s Hospital and the University of Melbourne, Melbourne, Vic, Australia
| | - Priya Nair
- St Vincent’s Hospital, Sydney, NSW, Australia,The University of New South Wales, Sydney, NSW, Australia
| | - Mate Rudas
- Royal Prince Alfred Hospital, Sydney, NSW, Australia,The University of Sydney, Sydney, NSW, Australia
| | | | - Robert N. Doughty
- Auckland District Health Board and University of Auckland, Auckland, New Zealand
| | - Gayathri Kumarasinghe
- The University of New South Wales, Sydney, NSW, Australia,Liverpool Hospital, Sydney, NSW, Australia
| | - Craig Juergens
- The University of New South Wales, Sydney, NSW, Australia,Liverpool Hospital, Sydney, NSW, Australia
| | - Paul G. Bannon
- Royal Prince Alfred Hospital, Sydney, NSW, Australia,The University of Sydney, Sydney, NSW, Australia
| | - Nicole K. Bart
- St Vincent’s Hospital, Sydney, NSW, Australia,The University of New South Wales, Sydney, NSW, Australia
| | - Clara K. Chow
- The University of Sydney, Sydney, NSW, Australia,Westmead Hospital, Sydney, NSW, Australia
| | - Jo-Dee Lattimore
- Royal Prince Alfred Hospital, Sydney, NSW, Australia,The University of Sydney, Sydney, NSW, Australia
| | - Leonard Kritharides
- The University of Sydney, Sydney, NSW, Australia,Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Richard Totaro
- Royal Prince Alfred Hospital, Sydney, NSW, Australia,The University of Sydney, Sydney, NSW, Australia
| | - Peter S. Macdonald
- St Vincent’s Hospital, Sydney, NSW, Australia,The University of New South Wales, Sydney, NSW, Australia,Corresponding author at:
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31
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Affiliation(s)
- Pankaj Jain
- Cardiology Department, St Vincent’s Hospital, Sydney, Australia
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32
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Hanff TC, Kaye DM, Hayward CS, Post MC, Malek F, Hasenfuβ G, Gustafsson F, Burkhoff D, Shah SJ, Litwin SE, Kahwash R, Hummel SL, Borlaug BA, Solomon SD, Lam CSP, Komtebedde J, Silvestry FE. Assessment of Predictors of Left Atrial Volume Response to a Transcatheter InterAtrial Shunt Device (from the REDUCE LAP-HF Trial). Am J Cardiol 2019; 124:1912-1917. [PMID: 31653352 DOI: 10.1016/j.amjcard.2019.09.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/06/2019] [Accepted: 09/10/2019] [Indexed: 11/15/2022]
Abstract
In patients with heart failure and preserved or mildly reduced ejection fractions (EF ≥40%), implantation of an interatrial shunt device (IASD) resulted in heterogenous changes of the left atrial (LA) volume. Baseline characteristics that correlate with a favorable decrease in LA volume are unknown. We hypothesized that a larger ratio of left to right atrial volume at baseline would correlate strongly with LA volume decongestion following IASD implantation. Reduce Elevated LA Pressure in Patients With Heart Failure was a multicenter study of the safety and feasibility of IASD implantation. Sixty-four patients with EF ≥40% underwent device implantation along with baseline conventional echocardiograms, speckle tracking echocardiography, and resting and exercise hemodynamics. Higher LA compliance (-4.2%, p = 0.048) and right atrial reservoir strain (-0.8%, p = 0.005) were independently associated with a percent decrease in the systolic LA volume index from baseline to 6-months. In conclusion, greater LA volume reduction following IASD implantation is associated with higher baseline compliance of the left atrium and higher reservoir strain of the right atrium.
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Affiliation(s)
- Thomas C Hanff
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - David M Kaye
- Alfred Hospital and Baker Heart and Diabetes Institute Melbourne, Victoria, Australia
| | | | | | | | - Gerd Hasenfuβ
- Heart Centre, Georg-August University, Gottingen, Germany
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | | | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sheldon E Litwin
- Medical University of South Carolina, Charleston, South Carolina
| | - Rami Kahwash
- Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Scott L Hummel
- University of Michigan and VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | | | | | | | | | - Frank E Silvestry
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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33
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Jain P, Shehab S, Muthiah K, Robson D, Granegger M, Drakos SG, Jansz P, Macdonald PS, Hayward CS. Insights Into Myocardial Oxygen Consumption, Energetics, and Efficiency Under Left Ventricular Assist Device Support Using Noninvasive Pressure-Volume Loops. Circ Heart Fail 2019; 12:e006191. [DOI: 10.1161/circheartfailure.119.006191] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Assessment of left ventricular (LV) recovery under continuous-flow LV assist device therapy is hampered by concomitant pump support. We describe derivation of noninvasive pressure-volume loops in continuous-flow LV assist device patients and demonstrate an application in the assessment of recovery.
Methods and Results:
Using pump controller parameters and noninvasive arterial pressure waveforms, central aortic pressure, outflow conduit pressure gradient, and instantaneous LV pressure were calculated. Instantaneous LV volumes were calculated from echocardiographic LV end-diastolic volume accounting for the integral of pump flow with respect to time and aortic ejection volume derived from the pump speed waveform. Pressure-volume loops were derived during pump speed adjustment and following bolus intravenous milrinone to assess changes in loading conditions and contractility, respectively. Fourteen patients were studied. Baseline noninvasive LV end-diastolic pressure correlated with invasive pulmonary arterial wedge pressure (
r
2
=0.57, root mean square error 5.0 mm Hg,
P
=0.003). Measured noninvasively, milrinone significantly increased LV ejection fraction (40.3±13.6% versus 36.8±14.2%,
P
<0.0001), maximum dP/dt (623±126 versus 555±122 mm Hg/s,
P
=0.006), and end-systolic elastance (1.03±0.57 versus 0.89±0.38 mm Hg/mL,
P
=0.008), consistent with its expected inotropic effect. Milrinone reduced myocardial oxygen consumption (0.15±0.06 versus 0.16±0.07 mL/beat,
P
=0.003) and improved myocardial efficiency (43.7±14.0% versus 41.2±15.5%,
P
=0.001). Reduced pump speed caused increased LV end-diastolic volume (190±80 versus 165±71 mL,
P
<0.0001) and LV end-diastolic pressure (14.3±10.2 versus 9.9±9.3 mm Hg,
P
=0.024), consistent with a predictable increase in preload. There was increased myocardial oxygen consumption (0.16±0.07 versus 0.14±0.06 mL O
2
/beat,
P
<0.0001) despite unchanged stroke work (
P
=0.24), reflecting decreased myocardial efficiency (39.2±12.7% versus 45.2±17.0%,
P
=0.003).
Conclusions:
Pressure-volume loops are able to be derived noninvasively in patients with the HeartWare HVAD and can detect induced changes in load and contractility.
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Affiliation(s)
- Pankaj Jain
- Cardiology Department, St Vincent’s Hospital, Sydney, Australia (P.J., S.S., K.M., D.R., P.J., P.S.M., C.S.H.)
| | - Sajad Shehab
- Cardiology Department, St Vincent’s Hospital, Sydney, Australia (P.J., S.S., K.M., D.R., P.J., P.S.M., C.S.H.)
| | - Kavitha Muthiah
- Cardiology Department, St Vincent’s Hospital, Sydney, Australia (P.J., S.S., K.M., D.R., P.J., P.S.M., C.S.H.)
| | - Desiree Robson
- Cardiology Department, St Vincent’s Hospital, Sydney, Australia (P.J., S.S., K.M., D.R., P.J., P.S.M., C.S.H.)
| | - Marcus Granegger
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charitè Universitätsmedizin, Berlin, Germany (M.G.)
| | | | - Paul Jansz
- Cardiology Department, St Vincent’s Hospital, Sydney, Australia (P.J., S.S., K.M., D.R., P.J., P.S.M., C.S.H.)
| | - Peter S. Macdonald
- Cardiology Department, St Vincent’s Hospital, Sydney, Australia (P.J., S.S., K.M., D.R., P.J., P.S.M., C.S.H.)
| | - Christopher S. Hayward
- Cardiology Department, St Vincent’s Hospital, Sydney, Australia (P.J., S.S., K.M., D.R., P.J., P.S.M., C.S.H.)
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34
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Huttner IG, Wang LW, Santiago CF, Horvat C, Johnson R, Cheng D, von Frieling-Salewsky M, Hillcoat K, Bemand TJ, Trivedi G, Braet F, Hesselson D, Alford K, Hayward CS, Seidman JG, Seidman CE, Feneley MP, Linke WA, Fatkin D. A-Band Titin Truncation in Zebrafish Causes Dilated Cardiomyopathy and Hemodynamic Stress Intolerance. Circ Genom Precis Med 2019; 11:e002135. [PMID: 30354343 DOI: 10.1161/circgen.118.002135] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Truncating variants in the TTN gene ( TTNtv) are common in patients with dilated cardiomyopathy (DCM) but also occur in the general population. Whether TTNtv are sufficient to cause DCM or require a second hit for DCM manifestation is an important clinical issue. Methods We generated a zebrafish model of an A-band TTNtv identified in 2 human DCM families in which early-onset disease appeared to be precipitated by ventricular volume overload. Cardiac phenotypes were serially assessed from 0 to 12 months using video microscopy, high-frequency echocardiography, and histopathologic analysis. The effects of sustained hemodynamic stress resulting from an anemia-induced hyperdynamic state were also evaluated. Results Homozygous ttna mutants had severe cardiac dysmorphogenesis and premature death, whereas heterozygous mutants ( ttnatv/+) survived into adulthood and spontaneously developed DCM. Six-month-old ttnatv/+ fish had reduced baseline ventricular systolic function and failed to mount a hypercontractile response when challenged by hemodynamic stress. Pulsed wave and tissue Doppler analysis also revealed unsuspected ventricular diastolic dysfunction in ttnatv/+ fish with prolonged isovolumic relaxation and increased diastolic passive stiffness in the absence of myocardial fibrosis. These defects reduced diastolic reserve under stress conditions and resulted in disproportionately greater atrial dilation than observed in wild-type fish. Conclusions Heterozygosity for A-band titin truncation is sufficient to cause DCM in adult zebrafish. Abnormalities of systolic and diastolic reserve in titin-truncated fish reduce stress tolerance and may contribute to a substrate for atrial arrhythmogenesis. These data suggest that hemodynamic stress may be an important modifiable risk factor in human TTNtv-related DCM.
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Affiliation(s)
- Inken G Huttner
- Molecular Cardiology and Biophysics Division (I.G.H., L.W.W., C.F.S., C.H., R.J., T.J.B., G.T., D.F.).,Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia. St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Kensington (I.G.H., L.W.W., C.F.S., D.H., C.S.H., M.P.F., D.F.)
| | - Louis W Wang
- Molecular Cardiology and Biophysics Division (I.G.H., L.W.W., C.F.S., C.H., R.J., T.J.B., G.T., D.F.).,Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia. St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Kensington (I.G.H., L.W.W., C.F.S., D.H., C.S.H., M.P.F., D.F.).,Cardiology Department, St Vincent's Hospital, Darlinghurst, NSW, Australia (L.W.W., C.S.H., M.P.F., D.F.)
| | - Celine F Santiago
- Molecular Cardiology and Biophysics Division (I.G.H., L.W.W., C.F.S., C.H., R.J., T.J.B., G.T., D.F.).,Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia. St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Kensington (I.G.H., L.W.W., C.F.S., D.H., C.S.H., M.P.F., D.F.)
| | - Claire Horvat
- Molecular Cardiology and Biophysics Division (I.G.H., L.W.W., C.F.S., C.H., R.J., T.J.B., G.T., D.F.)
| | - Renee Johnson
- Molecular Cardiology and Biophysics Division (I.G.H., L.W.W., C.F.S., C.H., R.J., T.J.B., G.T., D.F.)
| | - Delfine Cheng
- School of Medical Sciences, Bosch Institute, University of Sydney, Camperdown, NSW, Australia (D.C., F.B.)
| | | | - Karen Hillcoat
- Kevin Alford Cardiology, Port Macquarie, NSW Australia (K.H., K.A.)
| | - Timothy J Bemand
- Molecular Cardiology and Biophysics Division (I.G.H., L.W.W., C.F.S., C.H., R.J., T.J.B., G.T., D.F.)
| | - Gunjan Trivedi
- Molecular Cardiology and Biophysics Division (I.G.H., L.W.W., C.F.S., C.H., R.J., T.J.B., G.T., D.F.)
| | - Filip Braet
- School of Medical Sciences, Bosch Institute, University of Sydney, Camperdown, NSW, Australia (D.C., F.B.).,Cellular Imaging Facility, Charles Perkins Centre (F.B.).,Australian Centre for Microscopy and Microanalysis (F.B.)
| | - Dan Hesselson
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia. St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Kensington (I.G.H., L.W.W., C.F.S., D.H., C.S.H., M.P.F., D.F.).,University of Sydney, Camperdown, NSW, Australia. Diabetes and Metabolism Division, Garvan Institute of Medical Research, Darlinghurst, NSW, Australia (D.H.)
| | - Kevin Alford
- Kevin Alford Cardiology, Port Macquarie, NSW Australia (K.H., K.A.)
| | - Christopher S Hayward
- Cardiac Physiology and Transplantation Division (C.S.H., M.P.F.).,Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia. St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Kensington (I.G.H., L.W.W., C.F.S., D.H., C.S.H., M.P.F., D.F.).,Cardiology Department, St Vincent's Hospital, Darlinghurst, NSW, Australia (L.W.W., C.S.H., M.P.F., D.F.)
| | - J G Seidman
- Howard Hughes Medical Institute, MD (J.G.S.).,Department of Genetics, Harvard Medical School (J.G.S., C.E.S.)
| | - Christine E Seidman
- Department of Genetics, Harvard Medical School (J.G.S., C.E.S.).,Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (C.E.S.)
| | - Michael P Feneley
- Cardiac Physiology and Transplantation Division (C.S.H., M.P.F.).,Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia. St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Kensington (I.G.H., L.W.W., C.F.S., D.H., C.S.H., M.P.F., D.F.).,Cardiology Department, St Vincent's Hospital, Darlinghurst, NSW, Australia (L.W.W., C.S.H., M.P.F., D.F.)
| | - Wolfgang A Linke
- Institute of Physiology II, University of Muenster, Germany (M.v.F.-S., W.A.L.)
| | - Diane Fatkin
- Molecular Cardiology and Biophysics Division (I.G.H., L.W.W., C.F.S., C.H., R.J., T.J.B., G.T., D.F.).,Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia. St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Kensington (I.G.H., L.W.W., C.F.S., D.H., C.S.H., M.P.F., D.F.).,Cardiology Department, St Vincent's Hospital, Darlinghurst, NSW, Australia (L.W.W., C.S.H., M.P.F., D.F.)
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Newton PJ, Si S, Reid CM, Davidson PM, Hayward CS, Macdonald PS. Survival After an Acute Heart Failure Admission. Twelve-Month Outcomes From the NSW HF Snapshot Study. Heart Lung Circ 2019; 29:1032-1038. [PMID: 31708454 DOI: 10.1016/j.hlc.2019.09.004] [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] [Received: 07/14/2019] [Accepted: 09/02/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND The New South Wales (NSW) Heart Failure Snapshot sought to provide a contemporaneous profile of patients admitted with acute heart failure. We have previously reported the baseline results, and this paper reports the 30-day and 12-month outcomes. METHODS A prospective audit of consecutive patients admitted to 24 teaching hospitals across NSW and the Australian Capital Territory in July-August 2013 with acute heart failure. Follow-up data were obtained by integration of hospital administrative records and follow-up phone calls with the patients. RESULTS Eight hundred eleven (811) patients were recruited across the 24 sites. The NSW HF Snapshot was an elderly cohort (77 ± 14 yrs) with high comorbidity (mean Charlson Comorbidity Index 3.5 ± 2.6), and 71% were frail at baseline. Twenty-four per cent (24%) of patients were readmitted within 30-days post discharge. One hundred seventy-eight (178) patients died within 12 months post discharge. The independent predictors of death were frailty (Hazard Ratio 1.98 [95% Confidence interval 1.18-3.30]; p < 0.01) Charlson Comorbidity Index (HR 1.06 [95% CI 1.00-1.13]; p = 0.05); New York Heart Association (NYHA) class 4 (HR 2.62 [95% CI 1.32-5.22]; p < 0.01); eGFR<30 ml/min/1.73 m2 (HR 2.16 [95% CI 1.45-3.21]; p < 0.01); hypokalaemia at discharge (HR 2.55 [95% CI 1.44-4.51]; p < 0.01) and readmission within 30 days of baseline admission (HR 2.13 [95% CI 1.49-3.13]; p < 0.01). CONCLUSION In one of the largest prospective audits of acute heart failure outcomes in Australia, we found that short-term readmissions and mortality at 12 months remain high but were largely driven by patient-level factors.
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Affiliation(s)
- Phillip J Newton
- School of Nursing & Midwifery, Western Sydney University, Sydney, NSW, Australia.
| | - Si Si
- NHMRC Centre for Research Excellence in Cardiovascular Outcomes Improvement (CRECOI), School of Public Health, Curtin University, Perth, WA, Australia
| | - Christopher M Reid
- Monash Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health & Preventive Medicine, Monash University, Melbourne, Vic, Australia; School of Public Health, Curtin University, Perth, WA, Australia
| | - Patricia M Davidson
- School of Nursing, Johns Hopkins University, Baltimore, MD, USA; Faculty of Health, University of Technology, Sydney, NSW, Australia
| | - Christopher S Hayward
- St. Vincent's Hospital, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - Peter S Macdonald
- St. Vincent's Hospital, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
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36
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Hayward CS. Left ventricular assist device diagnostics using controller log files: The potential for predictive algorithms? J Heart Lung Transplant 2019; 38:1087-1088. [PMID: 31378577 DOI: 10.1016/j.healun.2019.07.002] [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] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 06/30/2019] [Accepted: 07/02/2019] [Indexed: 11/25/2022] Open
Affiliation(s)
- Christopher S Hayward
- Heart Failure and Transplant Unit, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia; Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia; School of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
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Jain P, Muthiah K, Shehab S, Robson D, Hayward CS. Dynamic flow responses to expiratory maneuvers in left ventricular assist device patients. J Heart Lung Transplant 2019; 38:669-674. [DOI: 10.1016/j.healun.2019.02.011] [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] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 01/25/2019] [Accepted: 02/20/2019] [Indexed: 10/27/2022] Open
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Lai JV, Muthiah K, Robson D, Prichard R, Walker R, Pin Lim C, Wang LW, Macdonald PS, Jansz P, Hayward CS. Impact of Pump Speed on Hemodynamics With Exercise in Continuous Flow Ventricular Assist Device Patients. ASAIO J 2019; 66:132-138. [PMID: 30913099 DOI: 10.1097/mat.0000000000000975] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
At fixed speed, the spontaneous increase in pump flow accompanying exercise in patients with continuous flow left ventricular assist devices (cfLVADs) is slight in comparison to normal physiologic response, limiting exercise capacity. We systematically exercised 14 patients implanted with an isolated HeartWare HVAD undergoing routine right heart catheterization at baseline and at maximal safe pump speed. In addition to hemodynamics, mixed venous oxygen saturation (SvO2), echocardiography and noninvasive mean arterial pressure, and heart rate were measured. Significantly greater pump flows were achieved with maximum pump speed compared with baseline speed at rest (mean ± standard deviation [SD]: 5.0 ± 0.7 vs. 4.6 ± 0.8 L/min) and peak exercise (6.7 ± 1.0 vs. 5.9 ± 0.9 L/min, p = 0.001). Pulmonary capillary wedge pressure was significantly reduced with maximum pump speed compared to baseline pump speed at rest (10 ± 4 vs. 15 ± 5 mmHg, p < 0.001) and peak exercise (27 ± 8 vs. 30 ± 8 mmHg, p = 0.002). Mixed venous oxygen saturation decreased with exercise (p < 0.001) but was unaffected by changes in pump speed. In summary, although higher pump speeds synergistically augment the increase in pump flow associated with exercise and blunt the exercise-induced rise in left heart filling pressures, elevated filling pressures and markedly diminished SvO2 persist at maximal safe pump speed, suggesting that physiologic flow increases are not met by isolated cfLVADs in the supported failing heart.
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Affiliation(s)
- Jacqueline V Lai
- From the Heart Failure and Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Kavitha Muthiah
- From the Heart Failure and Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
| | - Desiree Robson
- From the Heart Failure and Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Ros Prichard
- From the Heart Failure and Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Robyn Walker
- From the Heart Failure and Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Choon Pin Lim
- From the Heart Failure and Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Louis W Wang
- From the Heart Failure and Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Peter S Macdonald
- From the Heart Failure and Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
| | - Paul Jansz
- From the Heart Failure and Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Christopher S Hayward
- From the Heart Failure and Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
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Abstract
Right ventricular failure following left ventricular assist devices implantation is a serious complication associated with high mortality. In patients with or at high risk of developing right ventricular failure, biventricular support is recommended. Because univentricular support is associated with high survival rates, biventricular support is often undertaken as a last resort. With the advent of newer right ventricular and biventricular systems under design and testing, better differentiation is required to ensure optimal patients care. Clear guidelines on patient selection, time of intervention and device selection are required to improve patient outcomes.
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Affiliation(s)
- Sajad Shehab
- Cardiology Department, St Vincent's Hospital Sydney, Australia
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40
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Djordjevic D, Cawood BK, Rispin SK, Shah A, Yim LHH, Hayward CS, Ho JWK. CardiacProfileR: an R package for extraction and visualisation of heart rate profiles from wearable fitness trackers. Biophys Rev 2019; 11:119-121. [PMID: 30666509 DOI: 10.1007/s12551-019-00498-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 01/07/2019] [Indexed: 11/28/2022] Open
Affiliation(s)
- Djordje Djordjevic
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, 2010, Australia.,The University of New South Wales, Sydney, NSW, 2010, Australia
| | - Beni K Cawood
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, 2010, Australia.,The University of New South Wales, Sydney, NSW, 2010, Australia
| | - Sabrina K Rispin
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, 2010, Australia.,The University of New South Wales, Sydney, NSW, 2010, Australia
| | - Anushi Shah
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, 2010, Australia.,The University of New South Wales, Sydney, NSW, 2010, Australia
| | - Leo H H Yim
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, 2010, Australia.,The University of New South Wales, Sydney, NSW, 2010, Australia
| | - Christopher S Hayward
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, 2010, Australia.,The University of New South Wales, Sydney, NSW, 2010, Australia.,St Vincent's Hospital, Sydney, NSW, Australia
| | - Joshua W K Ho
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, 2010, Australia. .,The University of New South Wales, Sydney, NSW, 2010, Australia. .,School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong, China.
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Hannan MM, Xie R, Cowger J, Schueler S, de By T, Dipchand AI, Chu VH, Cantor RS, Koval CE, Krabatsch T, Hayward CS, Nakatani T, Kirklin JK. Epidemiology of infection in mechanical circulatory support: A global analysis from the ISHLT Mechanically Assisted Circulatory Support Registry. J Heart Lung Transplant 2019; 38:364-373. [PMID: 30733158 DOI: 10.1016/j.healun.2019.01.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/06/2019] [Accepted: 01/09/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Despite advances in device technology and treatment strategies, infection remains a major cause of adverse events (AEs) in mechanical circulatory support (MCS) patients. To characterize the epidemiology of MCS infection, we examined the type, location, and timing of infection in the International Society for Heart and Lung Transplantation Registry (ISHLT) for Mechanically Assisted Circulatory Support (IMACS) over 3 years, 2013 to 2015. METHODS Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) definitions were used to categorize AE infections occurring in MCS patients within IMACS. The IMACS infection variables were mapped to ISHLT definitions for infection where feasible. Three categories of MCS infection were defined as ventricular assist device (VAD) specific, VAD related, and non-VAD. RESULTS There were 10,171 patients enrolled from January 2013 through December 2015. Infection was the most common AE, with 3,788 patients (37%) experiencing ≥ 1 infection, and 6,758 AE infections reported overall. Non-VAD infection was the largest category, 4,501: 34.0% pneumonias, 30.6% non-VAD-related bloodstream infections (BSIs), 24.15% urinary tract infections (UTIs), and 10.2% gastrointestinal infections. VAD-specific infection was the second largest category, 1,756: 82.9% driveline, 12.8% pocket, and 4.3% pump/or cannula infections. VAD-related infection was the smallest category, 501: 47.5% BSIs, 47.5% mediastinitis, and 5.0% mediastinitis/pocket infections. All 3 categories were more frequently reported ≤ 3 months after implant. CONCLUSIONS Non-VAD infection, including pneumonia, BSI, UTI, and gastrointestinal infection, was the leading category of infection in MCS patients and the most frequently reported ≤ 3 months after implant. These results provide evidence to support resourcing and strengthening infection prevention strategy early after implantation in MCS.
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Affiliation(s)
- Margaret M Hannan
- Department of Clinical Microbiology, Mater Misercordiae University Hospital, University College Dublin, Dublin, Ireland.
| | - Rongbing Xie
- James and John Kirklin Institute for Research in Surgical Outcomes (KIRSO), University of Alabama, Birmingham, Alabama
| | - Jennifer Cowger
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Stephan Schueler
- Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Theo de By
- EUROMACS, EACTS, Windsor, United Kingdom
| | - Anne I Dipchand
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vivian H Chu
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Ryan S Cantor
- James and John Kirklin Institute for Research in Surgical Outcomes (KIRSO), University of Alabama, Birmingham, Alabama
| | - Christine E Koval
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio
| | - Thomas Krabatsch
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum, Berlin, Germany
| | - Christopher S Hayward
- Heart Failure and Transplant Unit, Vincent's Hospital, Sydney, New South Wales, Australia
| | | | - James K Kirklin
- James and John Kirklin Institute for Research in Surgical Outcomes (KIRSO), University of Alabama, Birmingham, Alabama
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Clifford R, Robson D, Gross C, Moscato F, Schima H, Jansz P, Macdonald PS, Hayward CS. Beat‐to‐beat detection of aortic valve opening in HeartWare left ventricular assist device patients. Artif Organs 2018; 43:458-466. [DOI: 10.1111/aor.13381] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 10/26/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Rachel Clifford
- Heart and Lung Transplant Unit St. Vincent's Hospital Darlinghurst New South Wales Australia
- St. Vincent's Clinical School, University of New South Wales Sydney Australia
| | - Desiree Robson
- Heart and Lung Transplant Unit St. Vincent's Hospital Darlinghurst New South Wales Australia
| | - Christoph Gross
- Center for Medical Physics and Biomedical Engineering Medical University of Vienna Vienna Austria
- Ludwig Boltzmann Cluster for Cardiovascular Research Vienna Austria
| | - Francesco Moscato
- Center for Medical Physics and Biomedical Engineering Medical University of Vienna Vienna Austria
- Ludwig Boltzmann Cluster for Cardiovascular Research Vienna Austria
| | - Heinrich Schima
- Center for Medical Physics and Biomedical Engineering Medical University of Vienna Vienna Austria
- Ludwig Boltzmann Cluster for Cardiovascular Research Vienna Austria
- Department of Cardiac Surgery Medical University of Vienna Vienna Austria
| | - Paul Jansz
- Heart and Lung Transplant Unit St. Vincent's Hospital Darlinghurst New South Wales Australia
| | - Peter S. Macdonald
- Heart and Lung Transplant Unit St. Vincent's Hospital Darlinghurst New South Wales Australia
- St. Vincent's Clinical School, University of New South Wales Sydney Australia
- Victor Chang Cardiac Research Institute Darlinghurst New South Wales Australia
| | - Christopher S. Hayward
- Heart and Lung Transplant Unit St. Vincent's Hospital Darlinghurst New South Wales Australia
- St. Vincent's Clinical School, University of New South Wales Sydney Australia
- Victor Chang Cardiac Research Institute Darlinghurst New South Wales Australia
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Shehab S, Rao S, Macdonald P, Newton PJ, Spratt P, Jansz P, Hayward CS. Outcomes of venopulmonary arterial extracorporeal life support as temporary right ventricular support after left ventricular assist implantation. J Thorac Cardiovasc Surg 2018; 156:2143-2152. [DOI: 10.1016/j.jtcvs.2018.05.077] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 04/30/2018] [Accepted: 05/21/2018] [Indexed: 01/16/2023]
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44
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Namasivayam M, Feneley MP, Hayward CS, Shaw M, Rao S, Jansz P, Muller DW. First Evaluation of Acute Left Ventricular Response to Off-Pump Transcatheter Mitral Valve Replacement in High-Risk Patients. JACC Cardiovasc Interv 2018; 11:2239-2240. [DOI: 10.1016/j.jcin.2018.07.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 07/24/2018] [Indexed: 11/29/2022]
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46
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Hayward CS. Balancing decisions in mechanical circulatory support: It's all in the timing. J Heart Lung Transplant 2018; 37:694-695. [PMID: 29628136 DOI: 10.1016/j.healun.2018.02.013] [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] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 02/18/2018] [Accepted: 02/23/2018] [Indexed: 11/27/2022] Open
Affiliation(s)
- Christopher S Hayward
- Heart Failure and Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia; Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia.
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47
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Kumarasinghe G, Jain P, Jabbour A, Lai J, Keogh AM, Kotlyar E, Jansz P, Macdonald PS, Hayward CS. Comparison of continuous-flow ventricular assist device therapy with intensive medical therapy in fixed pulmonary hypertension secondary to advanced left heart failure. ESC Heart Fail 2018; 5:695-702. [PMID: 29573567 PMCID: PMC6073035 DOI: 10.1002/ehf2.12284] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 02/12/2018] [Accepted: 02/20/2018] [Indexed: 11/11/2022] Open
Abstract
Aims Both ventricular assist device (VAD) and pulmonary vasodilator therapy have been shown in uncontrolled studies to improve pulmonary hypertension secondary to advanced left heart failure (Group 2 PH). This study aimed to compare haemodynamic benefits and survival in patients with fixed Group 2 PH treated with continuous‐flow VAD to intensive medical therapy. Methods and results Ninety‐five patients listed for heart transplantation with sequential right heart catheters were studied, 24 patients having fixed Group 2 PH (as defined by cardiac index < 2.8 L/min/m2, pulmonary capillary wedge pressure > 15 mmHg, and transpulmonary gradient ≥ 15 mmHg or pulmonary vascular resistance > 3.0 WU, unresponsive to vasodilator challenge). Ten patients received VAD therapy, and 14 patients received standard heart failure therapy with or without sildenafil, nitrates, or endothelin receptor antagonists. At repeat right heart catheterization, patients treated with VAD therapy demonstrated significant improvement in both transpulmonary gradient (19 vs. 12 mmHg, P = 0.046) and pulmonary vascular resistance (6.5 vs. 2.9 WU, P = 0.003) compared with baseline, while those treated with medical therapy did not (20.9 vs. 20.3 mmHg and 6.5 vs. 6.4 WU, P = NS for both). Patients who received VAD therapy were significantly more likely to achieve normalized transpulmonary gradient (8/10 vs. 4/14, P = 0.013) and were more likely to be listed for orthotopic heart transplantation (7/10 vs. 4/14, P < 0.05). There were no significant differences between groups in terms of all‐cause mortality. Conclusions Continuous‐flow VAD therapy more effectively reverses fixed Group 2 PH compared with medical therapy alone and may allow a higher rate of listing for orthotopic heart transplantation.
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Affiliation(s)
- Gayathri Kumarasinghe
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Pankaj Jain
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Darlinghurst, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia
| | - Andrew Jabbour
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Darlinghurst, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia.,Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
| | - Jacqueline Lai
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Anne M Keogh
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Darlinghurst, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia.,Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
| | - Eugene Kotlyar
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Darlinghurst, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia
| | - Paul Jansz
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Peter S Macdonald
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Darlinghurst, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia.,Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
| | - Christopher S Hayward
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Darlinghurst, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia.,Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
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48
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Spina R, Siriwardena M, Bart N, Namasivayam M, Connellan M, Jansz P, Spratt P, Hayward CS, Kotlyar E, Gunalingam B. Primary percutaneous coronary intervention for inferior ST-segment elevation myocardial infarction in a patient supported by the HeartWare left ventricular assist device. Intern Med J 2017; 47:1068-1071. [DOI: 10.1111/imj.13530] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 01/07/2017] [Accepted: 01/24/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Roberto Spina
- Department of Interventional Cardiology; St Vincent's Hospital; Sydney New South Wales Australia
| | - Maithri Siriwardena
- Department of Intensive Care; St Vincent's Hospital; Sydney New South Wales Australia
| | - Nicole Bart
- Department of Cardiac Transplantation and Advanced Heart Failure Service; St Vincent's Hospital; Sydney New South Wales Australia
| | - Mayooran Namasivayam
- Department of Cardiac Transplantation and Advanced Heart Failure Service; St Vincent's Hospital; Sydney New South Wales Australia
| | - Mark Connellan
- Department of Cardiothoracic Surgery; St Vincent's Hospital; Sydney New South Wales Australia
| | - Paul Jansz
- Department of Cardiothoracic Surgery; St Vincent's Hospital; Sydney New South Wales Australia
| | - Philip Spratt
- Department of Cardiothoracic Surgery; St Vincent's Hospital; Sydney New South Wales Australia
| | - Christopher S. Hayward
- Department of Cardiac Transplantation and Advanced Heart Failure Service; St Vincent's Hospital; Sydney New South Wales Australia
| | - Eugene Kotlyar
- Department of Cardiac Transplantation and Advanced Heart Failure Service; St Vincent's Hospital; Sydney New South Wales Australia
| | - Brendan Gunalingam
- Department of Interventional Cardiology; St Vincent's Hospital; Sydney New South Wales Australia
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Abstract
UNLABELLED Abstract Background: Thirst is a bothersome symptom of chronic heart failure (CHF) which impacts adversely on quality of life. Despite this, limited work has been done to investigate thirst as a symptom or to develop reliable and valid measures of thirst in CHF. The purpose of this manuscript is to establish which tools have been used in research to measure thirst in CHF. METHODS Medline, PubMed, Cumulative Index for Nursing and Allied Health, and Scopus were searched using following key words thirst, heart failure, measure, scale, randomised controlled trials and multicentre studies. RESULTS The search discovered 37 studies of which 6 studies met the inclusion criteria. One study was a research abstract and five were full-text studies. To date, there are only three measurement tools utilised in studies examining thirst in CHF patients [Visual Analogue Scale (VAS), Numeric Rating Scale and Thirst Distress Scale]. CONCLUSION Thirst in CHF is measured in a non-systematic way. In recent studies, the VAS has been used to measure thirst intensity. While this measurement tool is very easy and quick to administer, using a uni-dimensional tool in conjunction with a multi-dimensional tool may be beneficial to capture all dimensions of thirst. In order to manage thirst efficiently, consistent measurement of thirst in CHF is vital.
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Affiliation(s)
- Sabine M Allida
- Faculty of Health, Centre for Cardiovascular and Chronic Care, University of Technology Sydney, Ultimo, NSW, Australia
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50
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Hayward CS. Red blood cells and left ventricular assist devices-A lifespan under stress. J Heart Lung Transplant 2017; 36:609-610. [PMID: 28431982 DOI: 10.1016/j.healun.2017.03.015] [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] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 03/15/2017] [Accepted: 03/22/2017] [Indexed: 11/29/2022] Open
Affiliation(s)
- Christopher S Hayward
- Heart Failure and Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia; Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia.
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