Impact of Cardiac Resynchronization Therapy on Ventricular Arrhythmias and Survival After Durable Left Ventricular Assist Device Implantation.

The impact of cardiac resynchronization therapy (CRT) in patients receiving durable left ventricular assist device (LVAD) implantation remains unclear and there is no consensus regarding postoperative management. We sought to determine the impact of postoperative management of CRT on clinical outcomes following LVAD implantation. A total of 789 patients underwent LVAD implantation at our institution from 2007 to 2022 including 195 patients (24.7%) with preoperative CRT. Patients with preoperative CRT were significantly older and more frequently received an LVAD as destination therapy compared to patients without preoperative CRT. After LVAD implantation, 85 patients had CRT programmed "off" and 74 patients had CRT programmed "on." The risk of mortality was significantly increased amongst patients with preoperative CRT that was turned "on" following LVAD implantation compared to patients with preoperative CRT turned "off" following implant (subdistribution hazard ratio [sdHR] = 1.54; 1.06-2.37 95% confidence interval [CI]; p = 0.036). There was no significant difference between incidence of ventricular arrhythmias in patients with and without postoperative CRT "on" (35.1% vs. 48.2%; p = 0.095). Additional clinical trials are warranted to determine the best CRT programming strategy following LVAD implantation.

Preparing the Heart for a New Baby: Management of Pregnancy in Heart Transplant Recipients.

Heart transplant (HT) recipients are more frequently reaching childbearing age given improvement in median survival and outcomes after HT. Although most pregnancies in HT recipients have favorable outcomes, poor fetal outcomes and maternal complications such as hypertensive disorders of pregnancy are more common in HT recipients than in the general population. In this review, we summarize the current evidence to guide the management of pregnancy in HT recipients. Preconception counseling, focused on risk stratification and optimal timing of conception, is the first important step to optimize pregnancy outcomes. During pregnancy and in the postpartum period, frequent monitoring of graft function and immunosuppressive levels is recommended. Calcineurin inhibitors and corticosteroids should be the mainstay of treatment for both prevention and treatment of graft rejection. Delivery planning should follow usual obstetric indications, preferably with vaginal delivery at term using regional anesthesia. A multidisciplinary care team should be involved in management through all stages of pregnancy to ensure success.

Artificial intelligence approaches for phenotyping heart failure in U.S. Veterans Health Administration electronic health record.

AIMS: Heart failure (HF) is a clinical syndrome with no definitive diagnostic tests. HF registries are often based on manual reviews of medical records of hospitalized HF patients identified using International Classification of Diseases (ICD) codes. However, most HF patients are not hospitalized, and manual review of big electronic health record (EHR) data is not practical. The US Department of Veterans Affairs (VA) has the largest integrated healthcare system in the nation, and an estimated 1.5 million patients have ICD codes for HF (HF ICD-code universe) in their VA EHR. The objective of our study was to develop artificial intelligence (AI) models to phenotype HF in these patients. METHODS AND RESULTS: The model development cohort (n = 20 000: training, 16 000; validation 2000; testing, 2000) included 10 000 patients with HF and 10 000 without HF who were matched by age, sex, race, inpatient/outpatient status, hospital, and encounter date (within 60 days). HF status was ascertained by manual chart reviews in VA's External Peer Review Program for HF (EPRP-HF) and non-HF status was ascertained by the absence of ICD codes for HF in VA EHR. Two clinicians annotated 1000 random snippets with HF-related keywords and labelled 436 as HF, which was then used to train and test a natural language processing (NLP) model to classify HF (positive predictive value or PPV, 0.81; sensitivity, 0.77). A machine learning (ML) model using linear support vector machine architecture was trained and tested to classify HF using EPRP-HF as cases (PPV, 0.86; sensitivity, 0.86). From the 'HF ICD-code universe', we randomly selected 200 patients (gold standard cohort) and two clinicians manually adjudicated HF (gold standard HF) in 145 of those patients by chart reviews. We calculated NLP, ML, and NLP + ML scores and used weighted F scores to derive their optimal threshold values for HF classification, which resulted in PPVs of 0.83, 0.77, and 0.85 and sensitivities of 0.86, 0.88, and 0.83, respectively. HF patients classified by the NLP + ML model were characteristically and prognostically similar to those with gold standard HF. All three models performed better than ICD code approaches: one principal hospital discharge diagnosis code for HF (PPV, 0.97; sensitivity, 0.21) or two primary outpatient encounter diagnosis codes for HF (PPV, 0.88; sensitivity, 0.54). CONCLUSIONS: These findings suggest that NLP and ML models are efficient AI tools to phenotype HF in big EHR data to create contemporary HF registries for clinical studies of effectiveness, quality improvement, and hypothesis generation.

Identification and outcomes of KDIGO-defined chronic kidney disease in 1.4 million U.S. Veterans with heart failure.

AIMS: According to the Kidney Disease: Improving Global Outcomes (KDIGO) guideline, the definition of chronic kidney disease (CKD) requires the presence of abnormal kidney structure or function for >3 months with implications for health. CKD in patients with heart failure (HF) has not been defined using this definition, and less is known about the true health implications of CKD in these patients. The objective of the current study was to identify patients with HF who met KDIGO criteria for CKD and examine their outcomes. METHODS AND RESULTS: Of the 1 419 729 Veterans with HF not receiving kidney replacement therapy, 828 744 had data on ≥2 ambulatory serum creatinine >90 days apart. CKD was defined as estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 (n = 185 821) or urinary albumin-to-creatinine ratio (uACR) >30 mg/g (n = 32 730) present twice >3 months apart. Normal kidney function (NKF) was defined as eGFR ≥60 ml/min/1.73 m2, present for >3 months, without any uACR >30 mg/g (n = 365 963). Patients with eGFR <60 ml/min/1.73 m2 were categorized into four stages: 45-59 (n = 72 606), 30-44 (n = 74 812), 15-29 (n = 32 077), and <15 (n = 6326) ml/min/1.73 m2. Five-year all-cause mortality occurred in 40.4%, 57.8%, 65.6%, 73.3%, 69.7%, and 47.5% of patients with NKF, four eGFR stages, and uACR >30mg/g (albuminuria), respectively. Compared with NKF, hazard ratios (HR) (95% confidence intervals [CI]) for all-cause mortality associated with the four eGFR stages and albuminuria were 1.63 (1.62-1.65), 2.00 (1.98-2.02), 2.49 (2.45-2.52), 2.28 (2.21-2.35), and 1.22 (1.20-1.24), respectively. Respective age-adjusted HRs (95% CIs) were 1.13 (1.12-1.14), 1.36 (1.34-1.37), 1.87 (1.84-1.89), 2.24 (2.18-2.31) and 1.19 (1.17-1.21), and multivariable-adjusted HRs (95% CIs) were 1.11 (1.10-1.12), 1.24 (1.22-1.25), 1.46 (1.43-1.48), 1.42 (1.38-1.47), and 1.13 (1.11-1.16). Similar patterns were observed for associations with hospitalizations. CONCLUSION: Data needed to define CKD using KDIGO criteria were available in six out of ten patients, and CKD could be defined in seven out of ten patients with data. HF patients with KDIGO-defined CKD had higher risks for poor outcomes, most of which was not explained by abnormal kidney structure or function. Future studies need to examine whether CKD defined using a single eGFR is characteristically and prognostically different from CKD defined using KDIGO criteria.

Considerations Regarding Management of Heart Failure in Older Adults.

Understanding noncardiovascular comorbidities and geriatric syndromes in elderly patients with heart failure (HF) is important as the average age of the population increases. Healthcare professionals need to consider these complex dynamics when managing older adults with HF, especially those older than 80. A number of small studies have described associations between HF and major geriatric domains. With information on patients' cognitive, functional decline, and ability to adhere to therapy, physicians can plan for individualized treatment goals and recommendations for these patients.

Early Ventricular Arrhythmias After Left Ventricular Assist Device Implantation.

BACKGROUND: Although sustained ventricular arrhythmias (VAs) are a common complication after durable left ventricular assist device (LVAD) implantation, the incidence, risk factors, and prognostic implications of postoperative early VAs (EVAs) in contemporary patients with LVAD are poorly understood. METHODS AND RESULTS: A single-center retrospective analysis was performed of patients who underwent LVAD implantation from October 1, 2006, to October 1, 2022. EVA was defined as an episode of sustained VA identified ≤30 days after LVAD implantation. A total of 789 patients underwent LVAD implantation (mean age 62.9 ± 0. years 5, HeartMate 3 41.4%, destination therapy 43.3%). EVAs occurred in 100 patients (12.7%). A history of end-stage renal disease (odds ratio [OR] 5.6, 95% confidence interval [CI] 1.45-21.70), preoperative electrical storm (OR 2.82, 95% CI 1.11-7.16), and appropriate implantable cardiac defibrillator therapy before implantation (OR 2.8, 95% CI 1.26-6.19) are independently associated with EVAs. EVA was associated with decreased 30-day survival (hazard ratio 3.02, 95% CI 1.1-8.3, P = .032). There was no difference in transplant-free survival time between patients with and without EVAs (hazard ratio 0.82, 95% CI 0.5-1.4, P = .454). CONCLUSIONS: EVAs are common after durable LVAD implantation and are associated with an increased risk of 30-day mortality.

Arthroplasty for Treating Proximal Femur Metastatic Lesions May Be Associated with Lower Mortality Rates Compared to Intramedullary Nailing within the VA Healthcare System.

Metastatic bony disease is a significant health issue, with approximately 700,000 new cases annually that tend to metastasize to bones. The proximal femur in the appendicular skeleton is commonly affected. Our study aimed to investigate mortality rates and hospital stay duration in patients with pathologic proximal femur fractures treated with either intramedullary nailing or arthroplasty within the Veterans Health Administration system. In total, 679 patients (265 arthroplasty, 414 intramedullary nails) were identified through ICD-9 and CPT codes from 30 September 2010 to 1 October 2015. Hospital stays were similar for both groups (arthroplasty: 10.5 days, intramedullary nails: 11 days, p = 0.1). Mortality was associated with increased age and Gagne comorbidity scores (p < 0.001). Arthroplasty showed a survival benefit in the log-rank test (p = 0.018), and this difference persisted in the multivariate analysis after adjusting for age and comorbidities, with a hazard ratio of 1.3. Our study reported evidence that arthroplasty is associated with increased patient survival even when accounting for age and comorbidities in treating metastatic disease of the proximal femur.

Predictors and Outcomes of Sudden Cardiac Arrest in Heart Failure With Preserved Ejection Fraction: A Nationwide Inpatient Sample Analysis.

Sudden cardiac arrest (SCA) is the leading cause of cardiovascular mortality in heart failure with preserved ejection fraction (HFpEF), contributing to around 25% of deaths observed in pivotal HFpEF trials. However, predictors and outcomes of in-hospital SCA in HFpEF have not been well characterized. We queried the Nationwide Inpatient Sample (2016 to 2017) to identify adult hospitalizations with a diagnosis of HFpEF. Patients with acute or chronic conditions associated with SCA (e.g., acute myocardial infarction, acute pulmonary embolism, sarcoidosis) were excluded. We ascertained whether SCA occurred during these hospitalizations, identified predictors of SCA using multivariate logistic regression, and determined outcomes of SCA in HFpEF. Of 2,909,134 hospitalizations, SCA occurred in 1.48% (43,105). The mean age of the SCA group was 72.3 ± 12.4 years, 55.8% were women, and 66.4% were White. Presence of third-degree atrioventricular block (odds ratio [OR] 5.95, 95% confidence interval [CI] 5.31 to 6.67), left bundle branch block (OR 1.96, 95% CI 1.72 to 2.25), and liver disease (OR 1.87, 95% CI 1.73 to 2.02) were the leading predictors of SCA in HFpEF. After excluding patients with do-not-resuscitate status, the SCA group versus those without SCA had higher mortality (25.9% vs 1.6%), major bleeding complications (4.1% vs 1.7%), increased use of percutaneous coronary intervention (2.5% vs 0.7%), and mechanical circulatory assist device (1.2% vs 0.1%). These observational inpatient data suggest identifiable risk factors for SCA in HFpEF including cardiac arrhythmias. Further research is warranted to identify the best tools to risk-stratify patients with HFpEF to implement targeted SCA prevention strategies.

Stable Ventricular Fibrillation: A Paradigm Rather Than Septal Shift?

Awake patients in ventricular fibrillation is a phenomenon limited to patients who are mechanically supported. We describe a cohort of patients supported by left ventricular assist devices (LVADs) presenting to the emergency department (ED) at a high-volume LVAD center while in awake ventricular fibrillation (VF)/ventricular tachycardia (VT). Among 175 patients reviewed, a total of 19 LVAD patients presented to the ED in awake VF/VT between December 2015 and July 2021. On ED presentation, patients maintained a median mean arterial blood pressure (MAP) of 70 mm Hg with a mean LVAD flow of 3.77 L/minute. ED management included cardioversion in the majority of cases: 58% were defibrillated once, 21% were defibrillated multiple times, 68% received amiodarone, and 21% received lidocaine. Inpatient management included defibrillation, ablation, and antiarrhythmic initiation in 37%, 11%, and 84% of cases, respectively. In total, five patients (26%) died with one death attributed to recurrent VT. Our findings support the short-term tolerability of sustained ventricular arrhythmias in LVAD patients, as evidenced by the maintained MAPs and mental status. Clinical teams, however, should be aware of the potential harbinger for in-hospital mortality heralded by an awake VF/VT presentation.