Left Ventricular Assist Device in Patients With Alcohol Abuse or Illicit Drug Use.

The impact of substance abuse, including alcohol abuse or illicit drug use, on outcomes after left ventricular assist device (LVAD) implantation, has not been fully elucidated. Accordingly, to test the hypothesis that such a history would be associated with worse outcomes, we analyzed the Interagency Registry for Mechanically Assisted Circulatory Support registry. All patients from the Interagency Registry for Mechanically Assisted Circulatory Support registry who received a continuous-flow LVAD from June 2006 to December 2017 were included. The median follow-up duration was 12.9 months (interquartile range, 5.3 to 17.5). The final study group consisted of 15,069 patients, of which 1,184 (7.9%) had a history of alcohol abuse and 1,139 (7.6%) had a history of illicit drug use. The overall mortality rates in the alcohol, illicit drug, and control groups were 25%, 21%, and 29%, respectively. Cox regression analysis showed that having a history of alcohol abuse (hazard ratio, 0.97, 95% confidence interval, 0.84 to 1.13, p = 0.72) or illicit drug use (hazard ratio, 1.02, 95% confidence interval, 0.86 to 1.21, p = 0.81) was not significantly associated with increased risk of all-cause mortality when compared with general LVAD population. On the contrary, after adjusting for other covariates, a history of alcohol abuse or illicit drug use was significantly associated with increased device malfunction/pump thrombosis, device-related infection, or all-cause hospitalization (all p <0.05). Furthermore, After LVAD implantation, these patients had a lower quality of life assessed by the Kansas City Cardiomyopathy Questionnaire compared with those who did not. In conclusion, our findings suggest that patients with a history of alcohol abuse or illicit drug use are at risk for adverse device-related events with a lower quality of life after continuous-flow LVAD implantation compared with the general LVAD population.

Role of Acute Thrombosis in Coronavirus Disease 2019.

Patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are prone to venous, cerebrovascular, and coronary thrombi, particularly those with severe coronavirus disease 2019 (COVID-19). The pathogenesis is multifactorial and likely involves proinflammatory cascades, development of coagulopathy, and neutrophil extracellular traps, although further investigations are needed. Elevated levels of D-dimers are common in patients with COVID-19 and cannot be used in isolation to predict venous thromboembolism in people with SARS-CoV-2. If given early in hospital admission, therapeutic-dose heparin improves clinical outcomes in patients with moderate COVID-19. To date, antithrombotics have not improved outcomes in patients with severe COVID-19.

Percutaneous Interventions for Secondary Mitral Regurgitation.

Mitral regurgitation is frequently associated with ventricular dysfunction and carries a high mortality. Guideline-directed medical therapy, surgical mitral valve repair or replacement, and, in the setting of advanced heart failure, heart transplant and left ventricular assist devices have been the mainstay of treatment. However, rapid advancement in the field has resulted in approval of edge-to-edge mitral valve repair with the MitraClip, and there are several novel catheter-based percutaneous options in clinical trials. Percutaneous options, while promising, must be deployed in patients who are most likely to benefit, and thus, understanding the pathophysiology of specific subgroups of patients with functional mitral regurgitation (eg, disproportionate versus proportionate mitral regurgitation) is key to the success of new devices. We review the pathophysiology, percutaneous therapeutic treatment options, and ongoing clinical trials for functional mitral regurgitation.

Evolution of the SYNERGY bioresorbable polymer metallic coronary stent.

The SYNERGY stent is composed of thin, platinum-chromium metal alloy struts and an ultrathin, bioabsorbable poly-DL-lactide-co-glycolide polymer limited to the abluminal strut surface which elutes everolimus prior to complete resorption within 3-4 months. SYNERGY was designed to reduce inflammation and facilitate stent healing compared with permanent polymer drug eluting stents. This review summarizes the preclinical and clinical development of SYNERGY, its integration into clinical practice and future directions.

Development and Validation of Risk Prediction Models for Cardiovascular Events in Black Adults: The Jackson Heart Study Cohort.

IMPORTANCE: Cardiovascular risk assessment is a fundamental component of prevention of cardiovascular disease (CVD). However, commonly used prediction models have been formulated in primarily or exclusively white populations. Whether risk assessment in black adults is dissimilar to that in white adults is uncertain. OBJECTIVES: To develop and validate risk prediction models for CVD incidence in black adults, incorporating standard risk factors, biomarkers, and subclinical disease. DESIGN, SETTING, AND PARTICIPANTS: The Jackson Heart Study (JHS), a longitudinal community-based study of 5301 black adults in Jackson, Mississippi. Inclusive study dates were the date of a participant's first visit (September 2000 to March 2004) to December 31, 2011. The median (75th percentile) follow-up was 9.1 (9.7) years. The dates of the analysis were August 2013 to May 2015. Measurements included standard risk factors, including age, sex, body mass index, systolic and diastolic blood pressure, ratio of fasting total cholesterol to high-density lipoprotein cholesterol, estimated glomerular filtration rate, antihypertensive therapy, diabetes mellitus, and smoking; blood biomarkers; and subclinical disease measures, including ankle-brachial index, carotid intimal-medial thickness, and echocardiographic left ventricular hypertrophy and systolic dysfunction. MAIN OUTCOMES AND MEASURES: Incident CVD event was defined as the first occurrence of myocardial infarction, coronary heart disease death, congestive heart failure, stroke, incident angina, or intermittent claudication. Model performance was compared with the American College of Cardiology/American Heart Association (ACC/AHA) CVD risk algorithm and the Framingham Risk Score (FHS) refitted to the JHS data and evaluated in the Atherosclerosis Risk in Communities (ARIC) and Multi-Ethnic Study of Atherosclerosis cohorts. RESULTS: The study cohort comprised 3689 participants with mean (SD) age at baseline was 53 (11) years, and 64.8% (n = 2390) were female. Over a median of 9.1 years, 270 participants (166 women) experienced a first CVD event. A simple combination of standard CVD risk factors, B-type natriuretic peptide, and ankle-brachial index (model 6) yielded modest improvement over a model without B-type natriuretic peptide and ankle-brachial index (C statistic, 0.79; 95% CI, 0.75-0.83 [relative integrated discrimination improvement, 0.22; 95% CI, 0.15-0.30]). However, the reclassification improvement was not substantially different between model 6 and the ACC/AHA CVD Pooled Cohort risk equations or between model 6 and the FHS. The models discriminated reasonably well in the ARIC and Multi-Ethnic Study of Atherosclerosis data (C statistic range, 0.70-0.77). CONCLUSIONS AND RELEVANCE: Our findings using the JHS data in the present study are valuable because they confirm that current FHS and ACC/AHA risk algorithms work well in black individuals and are not easily improved on. A unique risk calculator for black adults may not be necessary.

Cardiopulmonary bypass and intra-aortic balloon pump use is associated with higher short and long term mortality after transcatheter aortic valve replacement: a PARTNER trial substudy.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) with the balloon-expandable Sapien transcatheter heart valve improves survival compared to standard therapy in patients with severe aortic stenosis (AS) and is noninferior to surgical aortic valve replacement (AVR) in patients at high operative risk. Nonetheless, a significant proportion of patients may require pre-emptive or emergent support with cardiopulmonary bypass (CPB) and/or intra-aortic balloon pump (IABP) during TAVR due to pre-existing comorbid conditions or as a result of procedural complications. OBJECTIVES: We hypothesized that patients who required CPB or IABP would have increased periprocedural complications and reduced long-term survival. In addition, we sought to determine whether preprocedural variables could predict the need for CPB and IABP. METHODS: The study population included 2,525 patients in the PARTNER Trial (Cohort A and B) and the continuing access registry (CAR). Patients that received CPB or IABP were compared to patients that did not receive either, and then further divided into those that received support pre-TAVR and those that were placed on support emergently. RESULTS: One-hundred sixty-three patients (6.5%) were placed on CPB and/or IABP. The use of CPB or IABP was associated with higher 1 year mortality (49.1% vs. 21.6%, P < 0.001). In multivariable analysis, utilization of CPB or IABP was an independent predictor of 30 day (HR 6.95) and 1-year (HR 2.56) mortality. Although mortality was highest in emergent cases, mortality was also greater in planned CPB and IABP cases compared with non-CPB/IABP cases (53.3% and 40.3% vs. 21.6%, P < 0.001). CONCLUSIONS: These findings indicate that CPB and IABP use in TAVR portends a poor prognosis and its utilization, particularly in the setting of pre-emptive use, needs reconsideration.

Mechanical circulatory support as a bridge to transplant or for destination therapy.

Mechanical circulatory support (MCS) frequently is used to treat medically refractory end-stage heart failure. Initially designed to be a bridge to transplantation, MCS also has proven itself as a durable therapy for patients who are not transplant candidates. As outcomes for patients with MCS have improved, research interest in device development has flourished, with many new device types under investigation. In addition to improvement of MCS devices, investigational work continues to achieve appropriate patient selection and complication management.

Distribution and determinants of Doppler-derived diastolic flow indices in African Americans: the Jackson Heart Study (JHS).

OBJECTIVES: The objective of this study is to investigate the distribution and determinants of diastolic function in a middle-aged cohort of African Americans (AA). BACKGROUND: The distribution and determinants of left ventricular (LV) diastolic function in AA are not well-described despite high rates of AA with diastolic heart failure and a five-fold higher risk of death in those with diastolic dysfunction (DD) compared to normal diastolic function. METHODS: Four categories of diastolic function were defined in JHS participants undergoing echocardiograms at the first examination (2001-2004) using mitral and pulmonary vein velocities. Investigators used logistic regression to assess the independent relation of DD to traditional risk factors and LV systolic dysfunction. RESULTS: Of the 3,571 study participants (mean age, 56 +/- 12 years; 63.9% female), 70.4% had normal diastolic function, and 18.0%, 10.6%, and 0.9% had mild, moderate, and severe DD, respectively. In the multivariable analysis, DD was significantly related to age (OR 1.2, 95% CI 1.1-1.4), male sex (OR 1.3 CI 1.0-1.5), LV systolic dysfunction (OR 1.5, CI 1.2-2.0), body mass index (OR 0.8, CI 0.8-0.9), and heart rate (OR 1.2; CI 1.1-1.2). The severity of DD was significantly related with age (OR 0.3; CI 0.3, 0.4), male sex (OR 1.6; CI 1.2-2.2), hypertension (OR 0.6, CI 0.4-0.8), and heart rate (OR 0.7; CI 0.6-0.8). CONCLUSION: This is the largest community-based analysis of LV diastolic function in middle-aged AA. DD was present in 29.5% and independently related to several traditional risk factors and LV systolic dysfunction.