Current Role of the CardioMEMS Device for Management of Patients with Heart Failure.

PURPOSE OF REVIEW: Heart failure (HF) remains a significant burden to our healthcare system and a leading cause of hospitalizations. Current reactive strategies to treat and manage HF have failed to reduce hospitalizations and improve survival. The CardioMEMS device has recently been demonstrated to improve quality of life in HF and reduce HF-related hospitalizations. Current HF management strategies are reviewed with a particular emphasis on the current role of the CardioMEMS device. RECENT FINDINGS: The CHAMPION trial is the only randomized trial looking at the CardioMEMS device. Patients managed with targeted pulmonary artery pressures resulted in 28% reduction in the primary end-point of HF-related hospitalization at 6 months (HR 0.72, 95% CI 0.60-0.85, p = 0.0002) and 37% reduction during the entire follow-up period, which averaged 15 months (HR 0.63, 95% CI 0.52-0.77, p < 0.0001). The prospective open-label post-approval study recently presented a 58% reduction in HF hospitalizations per patient year (HR 0.42, 95% CI 0.38-0.47, p < 0.0001). Management of HF using the CardioMEMS device has been shown to reduce HF hospitalizations and improve quality of life regardless of ejection fraction. Patients best suited for this device are those with recurrent congestive symptoms despite optimal medical therapy.

When should fractional flow reserve be performed to assess the significance of borderline coronary artery lesions: Derivation of a simplified scoring system.

OBJECTIVES: To derive a simplified scoring system (SSS) that can assist in selecting patients who would benefit from the application of fractional flow reserve (FFR). BACKGROUND: Angiographers base decisions to perform FFR on their interpretation of % diameter stenosis (DS), which is subject to variability. Recent studies have shown that the amount of myocardium at jeopardy is an important factor in determining the degree of hemodynamic compromise. METHODS: We conducted a retrospective multivariable analysis to identify independent predictors of hemodynamic compromise in 289 patients with 317 coronary vessels undergoing FFR. A SSS was derived using the odds ratios as a weighted factor. The receiver operator characteristics curve was used to identify the optimal cutoff (≥3) to discern a functionally significant lesion (FFR≤0.8). RESULTS: Male gender, left anterior descending artery apical wrap, disease proximal to lesion, minimal lumen diameter and % DS predicted abnormal FFR (≤0.8) and lesion location in the left circumflex predicted a normal FFR. Using a cutoff score of ≥3 on the SSS, a specificity of 90.4% (95% CI: 83.0-95.3) and a sensitivity of 38.0% (95% CI: 31.5-44.9) was generated with a positive predictive value of 89.0% (95% CI: 80.7%-94.6%) and negative predictive value of 41.6% (95% CI: 35.1%-48.3%). CONCLUSIONS: The decision to use FFR should be based not only on the % DS but also the size of the myocardial mass jeopardized. A score of ≥3 on the SSS should prompt further investigation with a pressure wire.

Real World Application of Stenting of Unprotected Left Main Coronary Stenosis: A Single-Center Experience.

BACKGROUND: The aim of this study was to summarize our single-center real-world experience with percutaneous coronary intervention (PCI) stenting of unprotected left main coronary artery (ULMCA). PCI-stenting of the ULMCA, while controversial, is emerging as an alternative to coronary artery bypass graft (CABG) surgery in select patients and clinical situations. METHODS: Between January 2005 and December 2008, PCI-stenting was performed on 125 patients with ULMCA lesions at our institution. Clinical and procedural data were recorded at the time of procedure, and patients were followed prospectively (mean 1.7 years; range 1 day-4.1 years) for outcomes, including death, myocardial infarction (MI), and target vessel revascularization (TVR). RESULTS: The majority of cases were urgent or emergent (82.5%), 50.4% of patients were non-surgical candidates, and 63.2% had 3 vessel disease. Many emergent patients presented in shock (62.1%), were not surgical candidates (89.7%), and had high mortality (20.7% in-hospital, 44.8% long-term). Mortality in the elective group was 6.3%. Cumulative death and TVR rates were 28.8% and 13.6%, respectively. Independent predictors of mortality were ejection fraction (EF) ≤ 35% (HR 2.4, CI 1.1 - 5.4) and left main bifurcation (HR 2.7, CI 1.2 - 5.7). CONCLUSIONS: PCI-stenting is a viable option in patients with LMCA disease and extends options to patients who are poor candidates for CABG. Elective PCI in low-risk CABG patients results in good long-term survival. Cumulative TVR is 13.6%. EF ≤ 35% and left main bifurcation are independently associated with increased mortality.

Prevalence and risk factors of pulmonary hypertension in patients with elevated pulmonary venous pressure and preserved ejection fraction.

Pulmonary hypertension (PH) is a well-recognized complication of left-sided heart failure with preserved left ventricular systolic function that portends a worse prognosis. The identification of risk factors may provide insight into possible mechanisms for the development of PH in this population. Targeting these risk factors could possibly attenuate the development of PH. The limited data available regarding the prevalence of PH and its risk factors in patients with heart failure with preserved left ventricular systolic function are based on echocardiography. To further study this, an institutional database was searched for all patients who underwent right-sided and left-sided cardiac catheterization with ventriculography from October 1996 to September 2007 who met the following criteria: left ventricular end-diastolic pressure (LVEDP) >15 mm Hg, a left ventricular ejection fraction > or =50%, and no significant left-sided cardiac valvular disease. The demographic, clinical, and hemodynamic data of these patients were then analyzed. Of 455 patients who met these criteria, 239 (52.5%) had PH, defined as mean pulmonary artery pressure >25 mm Hg. Using multivariate logistic regression, PH was strongly and independently associated with LVEDP > or =25 mm Hg (odds ratio 4.3), morbid obesity (odds ratio 3.4), and atrial arrhythmias (odds ratio 3.1). Other significant associations were age > or =80 years, chronic obstructive pulmonary disease, and dyspnea on exertion. In conclusion, PH is a frequent finding in patients with elevated LVEDPs and preserved left ventricular systolic function. Factors associated with its development are LVEDP > or =25 mm Hg, morbid obesity, atrial arrhythmias, age > or =80 years, chronic obstructive pulmonary disease, and dyspnea on exertion.

The impact of hematocrit drop on long-term survival after cardiac catheterization: insights from the Dartmouth Dynamic Registry.

BACKGROUND: The long-term prognostic implication of post-procedural hematocrit drops in patients undergoing cardiac catheterization outside the clinical trial setting is not well defined. METHODS: Data was prospectively collected from 12,661 patients undergoing diagnostic or interventional cardiac catheterization between July 1998 and July 2006. Patients were divided into three cohorts based upon the degree of hematocrit change: drop greater than 6, drop between 3 and 6, and drop less than 3. In-hospital major adverse events, 30-day mortality, and long-term all-cause mortality were recorded. RESULTS: Patients with larger reductions in hematocrit were more likely to be older, female, and have a higher baseline hematocrit, present with acute myocardial infarction, develop cardiogenic shock, require emergent catheterization, develop retroperitoneal bleeds and large hematomas, receive transfusions, have longer index hospitalizations, develop subacute stent thrombosis, and have higher 30-day and long-term mortality. An increase in long-term mortality was observed with progressive hematocrit drop. This finding is largely driven by early (30 day) mortality, as trends were no longer significant after rezeroing mortality. Hematocrit drop was not an independent risk factor for 30-day mortality. Transfusion and low baseline hematocrit were identified as independent predictors of near and long-term mortality. CONCLUSIONS: Periprocedural bleeding, defined by hematocrit drop, is associated with increased near-term and long-term mortality in patients undergoing diagnostic and therapeutic cardiac catheterization procedures. Long-term mortality is largely driven by up front 30-day mortality. Hematocrit drop was not an independent predictor for near-term mortality. Transfusion and low baseline hematocrit were independent predictors for near and long-term mortality.