Publications by authors named "Chantal ElAmm"

24 Publications

  • Page 1 of 1

Non-Invasive Imaging in the Evaluation of Cardiac Allograft Vasculopathy in Heart Transplantation: A Systematic Review.

Curr Probl Cardiol 2022 Jan 8:101103. Epub 2022 Jan 8.

Department of Medicine, University Hospitals, Cleveland, Ohio; Harrington Heart and Vascular Institute, University Hospitals and School of Medicine, Case Western Reserve University, Cleveland, Ohio. Electronic address:

Cardiac allograft vasculopathy (CAV) is the leading cause of long-term graft dysfunction in patients with heart transplantation and is linked with significant morbidity and mortality. Currently, the gold standard for diagnosing CAV is coronary imaging with intravascular ultrasound (IVUS) during traditional invasive coronary angiography (ICA). Invasive imaging, however, carries increased procedural risk and expense to patients in addition to requiring an experienced interventionalist. With the improvements in non-invasive cardiac imaging modalities such as transthoracic echocardiography (TTE), computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET), an alternative non-invasive imaging approach for the early detection of CAV may be feasible. In this systematic review, we explored the literature to investigate the utility of non-invasive imaging in diagnosis of CAV in >3000 patients across 49 studies. We also discuss the strengths and weaknesses for each imaging modality. Overall, all four imaging modalities show good to excellent accuracy for identifying CAV with significant variations across studies. Majority of the studies compared non-invasive imaging with ICA without intravascular imaging. In summary, non-invasive imaging modalities offer an alternative approach to invasive coronary imaging for CAV. Future studies should investigate longitudinal non-invasive protocols in low-risk patients after heart transplantation.
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http://dx.doi.org/10.1016/j.cpcardiol.2022.101103DOI Listing
January 2022

MELD score is predictive of 90-day mortality after veno-arterial extracorporeal membrane oxygenation support.

Int J Artif Organs 2021 Oct 26:3913988211054865. Epub 2021 Oct 26.

Division of Cardiovascular Disease, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.

Background: The Model for End-Stage Liver Disease (MELD) score was originally described as a marker of survival in chronic liver disease. More recently, MELD and its derivatives, MELD excluding INR (MELD-XI) and MELD with sodium (MELD-Na), have been applied more broadly as outcome predictors in heart transplant, left ventricular assist device placement, heart failure, and cardiogenic shock, with additional promising data to support the use of these scores for prediction of survival in those undergoing veno-arterial extracorporeal membrane oxygenation (VA ECMO).

Methods: This study assessed the prognostic impact of MELD in patients with cardiogenic shock undergoing VA ECMO via a single-center retrospective review from January 2014 to March 2020. MELD, MELD-XI, and MELD-Na scores were calculated using laboratory values collected within 48 h of VA ECMO initiation. Multivariate Cox regression analyses determined the association between MELD scores and the primary outcome of 90-day mortality. Receiver operating characteristics (ROC) were used to estimate the discriminatory power for MELD in comparison with previously validated SAVE score.

Results: Of the 194 patients, median MELD was 20.1 (13.7-26.2), and 90-day mortality was 62.1%. There was a significant association between MELD score and mortality up to 90 days (hazard ratio (HR) = 1.945, 95% confidence interval (95% CI) = 1.244-3.041, = 0.004) after adjustment for age, indication for VA ECMO, and sex. The prognostic significance of MELD score for 90-day mortality revealed an AUC of 0.645 (95% CI = 0.565-0.725, < 0.001). MELD-Na score and MELD-XI score were not associated with mortality.

Conclusion: MELD score accurately predicts long-term mortality and may be utilized as a valuable decision-making tool in patients undergoing VA ECMO.
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http://dx.doi.org/10.1177/03913988211054865DOI Listing
October 2021

LVAD Vasculitis Case Series: Suggestion of a New Fatal LVAD-Related Phenomenon.

JACC Case Rep 2021 Jul 7;3(7):1013-1017. Epub 2021 Jul 7.

Department of Advanced Heart Failure and Transplant, University Hospital Cleveland Medical Center, Harrington Heart Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA.

Left ventricular assist devices (LVADs) are surgically implanted mechanical devices indicated for patients with advanced heart failure and are known to come with several complications. Here we present a case series, and review 1 documented report, of LVAD vasculitis, a presumed new LVAD immune/humoral related phenomenon. ().
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http://dx.doi.org/10.1016/j.jaccas.2021.03.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8311371PMC
July 2021

Outcomes of Durable Mechanical Circulatory Support in Myocarditis: Analysis of the International Society for Heart and Lung Transplantation Registry for Mechanically Assisted Circulatory Support Registry.

ASAIO J 2021 Mar 22. Epub 2021 Mar 22.

From the Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio Department of Surgery, The University of Alabama at Birmingham, Birmingham, Alabama Department of Cardiology, Advanced Heart Failure and Transplant Cardiology, Henry Ford Health System, Detroit, Michigan Division of Cardiovascular Sciences, University of South Florida, Tampa, Florida Deutsches Herzzentrum Berlin, Berlin, Germany Department of Transplantation, National Cerebral and Cardiovascular Center, Osaka, Japan Department of Cardiothoracic & Vascular Surgery, Newcastle/Freeman Hospital, UK, Newcastle, United Kingdom Alfred Heart Center, Melbourne, Victoria, Australia Department of Cardiovascular Surgery, Montefiore Medical Center, Bronx, New York.

Myocarditis can be refractory to medical therapy and require durable mechanical circulatory support (MCS). The characteristics and outcomes of these patients are not known. We identified all patients with clinically-diagnosed or pathology-proven myocarditis who underwent mechanical circulatory support in the International Society for Heart and Lung Transplantation Registry for Mechanically Assisted Circulatory Support registry (2013-2016). The characteristics and outcomes of these patients were compared to those of patients with nonischemic cardiomyopathy (NICM). Out of 14,062 patients in the registry, 180 (1.2%) had myocarditis and 6,602 (46.9%) had NICM. Among patients with myocarditis, duration of heart failure was <1 month in 22%, 1-12 months in 22.6%, and >1 year in 55.4%. Compared with NICM, patients with myocarditis were younger (45 vs. 52 years, P < 0.001) and were more often implanted with Interagency Registry for Mechanically Assisted Circulatory Support profile 1 (30% vs. 15%, P < 0.001). Biventricular mechanical support ( biventricular ventricular assist device [BIVAD] or total artificial heart) was implanted more frequently in myocarditis (18% vs. 6.7%, P < 0.001). Overall postimplant survival was not different between myocarditis and NICM (left ventricular assist device: P = 0.27, BIVAD: P = 0.50). The proportion of myocarditis patients that have recovered by 12 months postimplant was significantly higher in myocarditis compared to that of NICM (5% vs. 1.7%, P = 0.0003). Adverse events (bleeding, infection, and neurologic dysfunction) were all lower in the myocarditis than NICM. In conclusion, although myocarditis patients who receive durable MCS are sicker preoperatively with higher needs for biventricular MCS, their overall MCS survival is noninferior to NICM. Patients who received MCS for myocarditis are more likely than NICM to have MCS explanted due to recovery, however, the absolute rates of recovery were low.
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http://dx.doi.org/10.1097/MAT.0000000000001430DOI Listing
March 2021

Relation of Pretransplant Peak Oxygen Consumption to Outcomes After Heart Transplantation.

Am J Cardiol 2020 07 23;127:52-57. Epub 2020 Apr 23.

Harrington Heart and Vascular Institute, Advanced Heart Failure and Transplant Center, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio. Electronic address:

Peak exercise oxygen consumption (pVO) is an important predictor of prognosis in patients with heart failure (HF). The association between pretransplant pVO and post-transplantation outcomes in HF patients has not been previously studied. We identified adult OHT recipients with available pVO in the United Network for Organ Sharing registry (2000 to 2015). Patients were divided into 3 categories using Weber classification: class B (pVO 16 to 20 ml/kg/min), class C (pVO 10 to 16 ml/kg/min), and class D (pVO <10 ml/kg/min). Postoperative outcomes (mortality, renal failure, rejection) were compared between the groups. A total of 9,623 patients were included in this analysis; the mean age was 54 ± 11 years, 74% were male, 75% were white and 59% had nonischemic etiology of HF. The mean pVO was 11.7 ± 3.6 ml/kg/min: 1,202 (12.5%) in class B, 6,055 (62.9%) in class C, and 2,366 (24.6%) were in class D. At a median follow-up of 6.1 years, 2,730 (28.4%) died. Post-transplantation survival decreased with decreasing pVO; 1 and 5-year survival: B (92%, 80%), C (90%, 79%), and D (87%, 75%), p <0.001 by log-rank. After multiple adjustments, patients in class D had significantly higher post-transplantation mortality compared with class C (Hazard Ratio (HR) 1.21 [1.03 to 1.43], p = 0.02). When analyzed as a continuous variable, each 1 ml/kg/min increase in pVO was associated with 2% decrease in mortality during follow-up (adjusted HR 0.98 [0.96 to 0.99], p <0.001). Patients in class D had significantly prolonged (>14 days) hospitalization (adjusted Odds Ratio (OR) 1.42 [1.20 to 1.68], p <0.001) and a trend toward increased need for dialysis (adjusted OR 1.36 [1.00 to 1.84], p = 0.05) compared with patients in class B. In this large cohort, lower pretransplant pVO was associated with greater mortality and morbidity after OHT. These results suggest that earlier transplantation might improve post-transplantation outcomes in advanced HF patients.
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http://dx.doi.org/10.1016/j.amjcard.2020.04.022DOI Listing
July 2020

Association between myocarditis and other immune-related adverse events secondary to immune checkpoint inhibitor use.

Int J Cancer 2020 09 6;147(6):1753-1754. Epub 2020 May 6.

Heart & Vascular Institute, University of South Florida, Tampa General Hospital & Moffitt Cancer Center, Tampa, Florida, USA.

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http://dx.doi.org/10.1002/ijc.32960DOI Listing
September 2020

Causes and predictors of 30-day readmissions in patients with cardiogenic shock requiring extracorporeal membrane oxygenation support.

Int J Artif Organs 2020 Apr 23;43(4):258-267. Epub 2019 Oct 23.

Advanced Heart Failure Center, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA.

Background: Cardiogenic shock is associated with significant mortality, morbidity, and healthcare cost. Utilization of extracorporeal membrane oxygenation in cardiogenic shock has increased in the United States. We sought to identify the rates and predictors of hospital readmissions in patients with cardiogenic shock after weaning from extracorporeal membrane oxygenation.

Methods: Using the 2016 Nationwide Readmission Database, we identified all patients (⩾18 years) with cardiogenic shock (ICD-10 CM R57.0) that have been implanted with extracorporeal membrane oxygenation (ICD-10-PSC of 5A15223) and were discharged alive (January-November 2016). We explored the rates, causes, and predictors of all-cause readmissions within 30 days.

Results: Out of 69,040 admissions with cardiogenic shock, 1641 (2.4%) underwent extracorporeal membrane oxygenation (581 were implanted during or after cardiac surgery). A total of 734 (44.7%) patients of all extracorporeal membrane oxygenations survived to discharge, and 661 were available for analysis. Out of those, 158 (23.9%) were readmitted within 30 days of discharge. More than 50% of these readmissions happened within the first 11 days. Out of 158 patients who were readmitted, 12 (7.4%) died during the readmission hospitalization. Leading causes of readmission were cardiovascular (31.6%) (heart failure: 24.1%, arrhythmia: 20.6%, neurovascular: 10.3%, hypertension: 10.3%, and endocarditis: 6.8%), followed by complications of medical/device care (17.7%), infection (11.3%), and gastrointestinal/liver (10.1%) complications. Factors associated with readmissions include the following: discharge to skilled nursing facility or with home healthcare (odds ratio: 2.10; 95% confidence interval: 1.18-3.74), durable ventricular assisted device implantation, asthma, and chronic liver disease.

Conclusion: Patients with cardiogenic shock who underwent extracorporeal membrane oxygenation had a readmission rate. Identifying patients at high risk of readmissions might help improve outcomes.
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http://dx.doi.org/10.1177/0391398819882025DOI Listing
April 2020

HeartMate II pump exchange with HeartMate III implantation to the descending aorta.

J Card Surg 2019 Jan 30;34(1):47-49. Epub 2018 Dec 30.

Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio.

Removal of the HeartMate II left ventricular assist device (LVAD) usually requires a sternotomy. We report a case of HeartMate III LVAD implantation to the descending aorta via a left thoracotomy while leaving most of the HeartMate II device in place to avoid redo-sternotomy.
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http://dx.doi.org/10.1111/jocs.13969DOI Listing
January 2019

Longitudinal Assessment of Vascular Function With Sunitinib in Patients With Metastatic Renal Cell Carcinoma.

Circ Heart Fail 2018 03;11(3):e004408

From the Division of Cardiovascular Medicine (A.B.C., J.C.F.) and Division of Oncology (N.A.), Department of Medicine, University of Utah, Salt Lake City; Department of Biostatistics, Epidemiology and Informatics (R.A.H., B.K.), Division of Cardiology (J.A.C., D.H., A.M.S., T.P., V.E., B.K.), Division of Hematology and Oncology (S.K., N.B.H., V.N.), and Division of Nephrology (R.T.), Department of Medicine, and Abramson Cancer Center (S.K., N.B.H., V.N., B.K.), University of Pennsylvania, Philadelphia; Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY (I.P.); Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin, Madison (S.E.); Division of Cardiovascular Medicine, Department of Medicine, University Hospitals Case Medical Center, Cleveland, OH (C.E.); Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (M.G.); and Division of Cardiology, Department of Medicine, Washington University in St Louis, MO (D.L.).

Background: Sunitinib, used widely in metastatic renal cell carcinoma, can result in hypertension, left ventricular dysfunction, and heart failure. However, the relationships between vascular function and cardiac dysfunction with sunitinib are poorly understood.

Methods And Results: In a multicenter prospective study of 84 metastatic renal cell carcinoma patients, echocardiography, arterial tonometry, and BNP (B-type natriuretic peptide) measures were performed at baseline and at 3.5, 15, and 33 weeks after sunitinib initiation, correlating with sunitinib cycles 1, 3, and 6. Mean change in vascular function parameters and 95% confidence intervals were calculated. Linear regression models were used to estimate associations between vascular function and left ventricular ejection fraction, longitudinal strain, diastolic function (E/e'), and BNP. After 3.5 weeks of sunitinib, mean systolic blood pressure increased by 9.5 mm Hg (95% confidence interval, 2.0-17.1; =0.02) and diastolic blood pressure by 7.2 mm Hg (95% confidence interval, 4.3-10.0; <0.001) across all participants. Sunitinib resulted in increases in large artery stiffness (carotid-femoral pulse wave velocity) and resistive load (total peripheral resistance and arterial elastance; all <0.05) and changes in pulsatile load (total arterial compliance and wave reflection). There were no statistically significant associations between vascular function and systolic dysfunction (left ventricular ejection fraction and longitudinal strain). However, baseline total peripheral resistance, arterial elastance, and aortic impedance were associated with worsening diastolic function and filling pressures over time.

Conclusions: In patients with metastatic renal cell carcinoma, sunitinib resulted in early, significant increases in blood pressure, arterial stiffness, and resistive and pulsatile load within 3.5 weeks of treatment. Baseline vascular function parameters were associated with worsening diastolic but not systolic function.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.117.004408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6360089PMC
March 2018

Myocarditis and cardiomyopathy.

Curr Opin Cardiol 2018 05;33(3):341-346

University Hospitals Cleveland Medical Center, Harrington Heart and Vascular Institute, Cleveland, Ohio, USA.

Purpose Of Review: The aim of this study is to summarize the literature describing the pathogenesis, diagnosis and management of cardiomyopathy related to myocarditis.

Recent Findings: Myocarditis has a variety of causes and a heterogeneous clinical presentation with potentially life-threatening complications. About one-third of patients will develop a dilated cardiomyopathy and the pathogenesis is a multiphase, mutlicompartment process that involves immune activation, including innate immune system triggered proinflammatory cytokines and autoantibodies. In recent years, diagnosis has been aided by advancements in cardiac MRI, and in particular T1 and T2 mapping sequences. In certain clinical situations, endomyocardial biopsy (EMB) should be performed, with consideration of left ventricular sampling, for an accurate diagnosis that may aid treatment and prognostication.

Summary: Although overall myocarditis accounts for a minority of cardiomyopathy and heart failure presentations, the clinical presentation is variable and the pathophysiology of myocardial damage is unique. Cardiac MRI has significantly improved diagnostic abilities, but endomyocardial biopsy remains the gold standard. However, current treatment strategies are still focused on routine heart failure pharmacotherapies and supportive care or cardiac transplantation/mechanical support for those with end-stage heart failure.
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http://dx.doi.org/10.1097/HCO.0000000000000514DOI Listing
May 2018

Pulmonary Hemorrhage following Edge-to-Edge Mitral Valve Repair.

Case Rep Cardiol 2017 19;2017:4854736. Epub 2017 Jun 19.

Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.

Mitral valve repair with the MitraClip device has emerged as an effective treatment option for patients with severe mitral regurgitation and contraindications for surgical interventions. While the procedure is not known to cause pulmonary complications, we describe two cases of pulmonary hemorrhage following percutaneous mitral valve repair. The patients did well with supportive care and reinitiation of anticlotting agents was well tolerated after resolution of bleeding.
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http://dx.doi.org/10.1155/2017/4854736DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5494550PMC
June 2017

Heart Transplantation in Giant Cell Myocarditis: Analysis of the United Network for Organ Sharing Registry.

J Card Fail 2017 Jul 24;23(7):566-569. Epub 2017 Apr 24.

Advanced Heart Failure and Transplant Center, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio. Electronic address:

Background: Giant cell myocarditis (GCM) is a lethal, rapidly progressive disease, for which heart transplantation is the treatment of choice. We sought to describe the characteristics and outcomes of patients with GCM who undergo heart transplantation.

Methods And Results: We used the United Network for Organ Sharing thoracic organ transplantation registry to identify adults with GCM as the primary diagnosis and compared their characteristics and outcomes with patients who underwent transplantation for other types of myocarditis and for idiopathic dilated cardiomyopathy (IDCMP). A total of 32 patients with GCM were compared with 219 patients with myocarditis and 14,221 patients with IDCMP. Median age at listing for GCM was 52 years (interquartile range 40-55 y), and the majority were white (94%), male (63%), and listed as 1A (44%). Biventricular assist devices were used more frequently in GCM compared with IDCMP (31% vs 2%; P < .001). After transplantation, there were no statistically significant differences among GCM, myocarditis, and IDCMP patients regarding pacemaker implantation, dialysis initiation, or stroke rate. GCM patients had increased risk of acute rejection compared with IDCMP patients (16% vs 5.0%; P = .021) but no difference in rehospitalization for rejection among the 3 etiologies (P = .88). The cumulative survivals for GCM patients at 1, 5, and 10 years were 94%, 82%, and 68%, respectively, which was similar to the other etiologies (P = .11).

Conclusions: Compared with patients with IDCMP, those with GCM present more acutely and have significantly higher utilization of biventricular mechanical circulatory support. Despite higher rates of early rejection, post-transplantation survival of patients with GCM was similar to that of other myocarditides and IDCMP.
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http://dx.doi.org/10.1016/j.cardfail.2017.04.015DOI Listing
July 2017

Prospective Evaluation of Sunitinib-Induced Cardiotoxicity in Patients with Metastatic Renal Cell Carcinoma.

Clin Cancer Res 2017 Jul 14;23(14):3601-3609. Epub 2017 Feb 14.

Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania.

To prospectively evaluate cardiotoxicity risk with sunitinib in metastatic renal cell carcinoma (mRCC) routine clinical practice using comprehensive echocardiography and biomarker phenotyping. In a multicenter prospective study of 90 patients with mRCC, echocardiography and biomarkers of cardiovascular injury and stress were quantified at baseline, 3.5, 15, and 33 weeks following sunitinib initiation. These "on-drug" visits corresponded to cycles 1, 3, and 6, respectively. Left ventricular (LV) dysfunction was defined as an absolute decline in LV ejection fraction (LVEF) by ≥10% to a value of <50%. Conditional survival analyses predicted the risk of LV dysfunction. Linear mixed-effects models estimated changes in LVEF, high-sensitivity Troponin I (hsTnI), and B-type natriuretic peptide (BNP) over time. The predicted risk of LV dysfunction by cycle 6 was 9.7% (95% confidence interval, 3%-17%). The majority of events occurred in the first treatment cycle. This risk diminished to 5% and 2% in patients who had not experienced dysfunction by the completion of cycles 1 and 3, respectively. All evaluable patients who experienced LV dysfunction had subsequent improvement in LVEF with careful management. Six patients (6.7%) developed hsTnI elevations >21.5 pg/mL, and 11 additional patients (12.2%) developed BNP elevations >100 pg/mL. These elevations similarly tended to occur early and resolved over time. On average, patients with mRCC receiving sunitinib exhibit modest declines in LVEF and nonsignificant changes in hsTnI and BNP. However, approximately 9.7% to 18.9% of patients develop more substantive abnormalities. These changes occur early and are largely recoverable with careful management. .
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http://dx.doi.org/10.1158/1078-0432.CCR-16-2869DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5516884PMC
July 2017

Characteristics and Outcomes of Patients With Myocarditis Listed for Heart Transplantation.

Circ Heart Fail 2016 12;9(12)

From the Advanced Heart Failure and Transplant Center, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, OH.

Background: Myocarditis can cause dilated cardiomyopathy resulting in end-stage heart failure requiring advanced therapies. There is little contemporary information on the clinical progression, need for mechanical circulatory support, and outcomes of orthotopic heart transplantation of these patients.

Methods And Results: We queried the UNOS database (United Network for Organ Sharing) for all adults listed for orthotopic heart transplantation (2000-2015) with a listed diagnosis of myocarditis. Comparative and survival analyses were performed. Of 45 941 adults listed for orthotopic heart transplantation during this period, we identified 299 patients (0.7%) with the diagnosis of myocarditis. Compared with patients with nonischemic cardiomyopathy (NICM) and ischemic cardiomyopathy (ICM), myocarditis patients were younger (myocarditis 43.4±14.2 years, NICM 49.8±12.4 years, and ICM 57.5±8.0 years; P<0.001) and more frequently listed as status 1A (myocarditis 44% versus NICM 21% versus ICM 21%; P<0.001), with significantly higher need for mechanical ventilation (myocarditis 11% versus NICM 2% versus ICM 4%; P<0.001), biventricular mechanical circulatory support (myocarditis 19% versus NICM 2%, versus ICM 2%; P<0.001), and extracoroporeal membrane oxygenation (myocarditis 5% versus NICM 0.4% versus ICM 1%; P<0.001). Additionally, patients with myocarditis had higher likelihood of delisting for clinical improvement (hazard ratio, 2.49 [95% confidence interval, 1.63-3.79] versus ICM and hazard ratio, 2.12 [95% confidence interval, 1.40-3.22] versus NICM; P<0.001). Despite higher allosensitization, patients with myocarditis had similar post-transplant rejection, retransplantation, and survival rates compared with other groups.

Conclusions: Patients with the diagnosis of myocarditis listed for orthotopic heart transplantation are younger, sicker, and recover more frequently but require more biventricular mechanical circulatory support. Heart transplantation survival is comparable to that of patients with other types of heart failure.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.116.003259DOI Listing
December 2016

First-in-Human Experience With Transcatheter Mitral Valve-in-Valve Implantation During Left Ventricular Assist Device Placement.

Circ Heart Fail 2016 11;9(11)

From the Advanced Heart Failure and Transplantation (G.O., S.A.-K., M.R.R., G.H.O., M.G., C.E., M.Z., M.F.), Interventional Cardiology (G.F.A.), and Cardiothoracic Surgery (B.M., S.V.D., S.J.P., B.S.), Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, OH.

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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.116.003458DOI Listing
November 2016

Left Ventricular Assist Devices or Inotropes for Decreasing Pulmonary Vascular Resistance in Patients with Pulmonary Hypertension Listed for Heart Transplantation.

J Card Fail 2017 Mar 30;23(3):209-215. Epub 2016 Jun 30.

Advanced Heart Failure & Transplant Center, Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio. Electronic address:

Background: Fixed pulmonary hypertension is common in patients with advanced heart failure and is a contraindication for heart transplantation. Left ventricular assist devices (LVAD) and inotropes have been used to reduce pulmonary vascular resistance (PVR) and allow transplantation. However, little is known about the efficacy of this strategy.

Methods: We queried the United Network for Organ Sharing registry for all adult patients (age ≥18 years) listed for primary heart transplantation (2008-2014) with PVR of >5 wood units (WU) or transpulmonary gradient >16 mmHg who were treated with LVAD or IV inotropes as status 1a, 1b, or 7. We compared waitlist mortality/delisting and absolute changes in hemodynamics between listing and transplantation.

Results: Of 18,009 patients listed during the study period, 1016 were included in the analysis (393 LVAD, 623 inotropes), with a mean age of 52.9 ± 11.6 years, 74% male, and 38% had ischemic etiology. Mean PVR was 5.7 ± 2.4 WU and transpulmonary pressure gradient 19.3 ± 5.3 mmHg. Compared with the inotrope group, LVAD patients were more likely listed as status 1A (32.8% vs 18.1%, P < .001), had lower PVR (5.3 WU vs 5.9 WU, P = .001), and higher cardiac output (4.1 vs 3.6 L/min, P < .001). After a mean of 239 days, PVR decreased by 1.71 WU in the LVAD group vs 1.85 WU in the inotrope group (P = .52). PVR normalization (<2.5 WU) occurred at similar rates among those treated with inotropes and LVAD (30.7% vs 35.6%, P = .228). Waitlist mortality was similar between LVAD and inotropes (adjusted P = .837). Absolute PVR and transpulmonary pressure gradient reductions correlated with time on the waitlist (P < .001 for both comparisons).

Conclusion: Only about one-third of patients with fixed pulmonary hypertension achieve normalization of PVR before transplant with either LVAD or inotropes. Similar waitlist mortality was observed among patients bridged with either strategy.
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http://dx.doi.org/10.1016/j.cardfail.2016.06.421DOI Listing
March 2017

Heart failure in patients with human immunodeficiency virus infection: Epidemiology and management disparities.

Int J Cardiol 2016 Sep 13;218:43-46. Epub 2016 May 13.

Case Western Reserve University School of Medicine, Cleveland, OH, USA; University Hospitals Case Medical Center, Cleveland, OH, USA. Electronic address:

Background: Persons living with HIV are at a higher risk of cardiovascular disease despite effective antiretroviral therapy and dramatic reductions in AIDS-related conditions. We sought to identify the epidemiology of heart failure (HF) among persons living with HIV in the United States in an era of contemporary antiretroviral therapy.

Methods: Explorys is an electronic healthcare database that aggregates medical records from 23 healthcare systems nationwide. Using systemized nomenclature of medicine-clinical terms (SNOMED-CT), we identified adult patients (age>18), who had active records over the past year (September 2014-September 2015). We described the prevalence of HF in HIV patients by demographics and treatment and compared them to HIV-uninfected controls.

Results: Overall, there were 36,400 patients with HIV and 12,208,430 controls. The overall prevalence of HF was 7.2% in HIV and 4.4% in controls (RR 1.66 [1.60-1.72], p<0.0001). The relative risk of HF associated with HIV infection was higher among women and younger age groups. Patients receiving antiretroviral therapy had only marginally lower risk (6.4% vs. 7.7%, p<0.0001) of HF compared to those who were untreated. Compared to uninfected patients with HF, HIV patients with HF were less likely to receive antiplatelet drugs, statins, diuretics, and ACE/ARBs (p<0.0001 for all comparisons). For patients with HIV and HF, receiving care from a cardiologist was associated with higher use of antiplatelets, statins, betablockers, ACE/ARBs, and diuretics.

Conclusions: Persons with HIV are at higher risk for HF in this large contemporary sample that includes both men and women. Although the prevalence of heart failure is higher in older HIV patients, the relative risk associated with HIV is highest in young people and in women. HIV patients are less likely to have HF optimally treated, but cardiology referral was associated with higher treatment rates.
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http://dx.doi.org/10.1016/j.ijcard.2016.05.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4907816PMC
September 2016

Effect of Hepatitis C Positivity on Survival in Adult Patients Undergoing Heart Transplantation (from the United Network for Organ Sharing Database).

Am J Cardiol 2016 07 20;118(1):132-7. Epub 2016 Apr 20.

Divisions of Cardiovascular Surgery and Cardiology, Harrington Heart and Vascular Institute, University Hospitals, Case Western Reserve University, Cleveland, Ohio.

Concerns exist regarding orthotropic heart transplantation in hepatitis C virus (HCV) seropositive recipients. Thus, a national registry was accessed to evaluate early and late outcome in HCV seropositive recipients undergoing heart transplant. Retrospective analysis of the United Network for Organ Sharing registry (1991 to 2014) was performed to evaluate recipient profile and clinical outcome of patients with HCV seropositive (HCV +ve) and seronegative (HCV -ve). Adjusted results of early mortality and late survival were compared between cohorts. From 23,507 patients (mean age 52 years; 75% men), 481 (2%) were HCV +ve (mean age 52 years; 77% men). Annual proportion of HCV +ve recipients was comparable over the study period (range 1.3% to 2.7%; p = 0.2). The HCV +ve cohort had more African-American (22% vs 17%; p = 0.01), previous left ventricular assist device utilization (21% vs 14%; p <0.01) and more hepatitis B core Ag+ve recipients (17% vs 5%; p <0.01). However, both cohorts were comparable in terms of extracorporeal membrane oxygenator usage (p = 0.7), inotropic support (p = 0.2), intraaortic balloon pump (p = 0.7) support, serum creatinine (p = 0.7), and serum bilirubin (p = 0.7). Proportion of status 1A patients was similar (24% HCV + vs 21% HCV -); however, wait time for HCV +ve recipients were longer (mean 23 vs 19 days; p <0.01). Among donor variables, age (p = 0.8), hepatitis B status (p = 0.4), and Center for Diseases Control high-risk status (p = 0.9) were comparable in both cohorts. At a median follow-up of 4 years, 67% patients were alive, 28% died, and 1.1% were retransplanted (3.4% missing). Overall survival was worse in the HCV+ cohort (64.3% vs 72.9% and 43.2% vs 55% at 5 and 10 years; p <0.01), respectively. Late renal (odds ratio [OR] 1.2 [1 to 1.6]; p = 0.02) and liver dysfunction (odds ratio 4.5 [1.2 to 15.7]; p = 0.01) occurs more frequently in HCV +ve recipients. On adjusted analysis, HCV seropositivity is associated with poorer survival (hazard ratio for mortality 1.4 [1.1 to 1.6]; p <0.001). In conclusion, a small proportion of patients receiving a heart transplant in the United States have hepatitis C. Despite comparable preoperative hepatic function, hepatitis C seropositive recipients demonstrate poorer long-term survival.
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http://dx.doi.org/10.1016/j.amjcard.2016.04.023DOI Listing
July 2016

Model for end-stage liver disease excluding international normalized ratio (MELD-XI) score predicts heart transplant outcomes: Evidence from the registry of the United Network for Organ Sharing.

J Heart Lung Transplant 2016 Feb 9;35(2):222-7. Epub 2015 Oct 9.

Advanced Heart Failure and Transplantation Center, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio; Division of Cardiovascular Surgery, University Hospitals Case Medical Center, Cleveland, Ohio.

Background: Hepato-renal function is a valuable predictor of success after left ventricular assist device therapy and heart transplantation. Hence, we analyzed the importance of the Model for End-stage Liver Disease excluding international normalized ratio (MELD-XI) score to outcomes after heart transplant.

Methods: Adults undergoing heart transplant from the United Network for Organ Sharing (UNOS) database were identified (1994 to 2014). Individual MELD-XI scores were calculated; patients were stratified by MELD-XI quartiles (Q1 to Q4). Multivariate logistic regression and the Cox proportional hazard model were implemented to determine any association between MELD-XI scores, survival and other outcomes.

Results: From 39,711 patients undergoing OHT during the study period, MELD-XI score [median 10.7 (interquartile range 7.0 to 14.4)] was calculated for 36,005 patients (76% male and 75% white, 34% Status 1A). Higher MELD-XI scores had higher rates of pre-transplant extracorporeal membrane oxygenation, intra-aortic balloon pump, inotrope use and mechanical ventilation (p < 0.001 for all). Adjusted long-term mortality (median follow-up 8.1 years) was associated with MELD-XI score (hazard ratio [HR] 1.021 [1.016 to 1.026], p < 0.001). The highest MELD-XI quartile was associated with an HR 1.364 [1.255 to 1.482] risk of mortality compared with Q1. MELD-XI score was also associated with increased post-transplant infections (adjusted HR Q4 vs Q1: 1.364 [1.153 to 1.614], p < 0.001), stroke (adjusted HR Q4 vs Q1: 1.410 [1.074 to 1.852], p = 0.013), dialysis (adjusted HR Q4 vs Q1: 3.982 [3.386 to 4.683], p < 0.001), rejection (adjusted HR Q4 vs Q1: 1.519 [1.286 to 1.795], p = 0.003) and prolonged hospitalization (adjusted HR Q4 vs Q1: 1.635 [1.429 to 1.871], p < 0.001).

Conclusion: Hepato-renal dysfunction, measured with MELD-XI score, predicts morbidity and mortality in patients undergoing orthotopic heart transplantation. Etiology of hepato-renal dysfunction should be sought and treated before heart transplantation.
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http://dx.doi.org/10.1016/j.healun.2015.10.008DOI Listing
February 2016

Platelet inhibition with ticagrelor for left ventricular assist device thrombosis.

Circ Heart Fail 2015 May;8(3):649-51

From the Department of Medicine (G.H.O., S.G.A., C.E., M.Y.Q., R.D.B., M.N.O., M.G., D.I.S.) and Department of Surgery (S.D., B.M., S.J.P.), Advanced Heart Failure and Transplant Center, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH.

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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.115.002096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4441041PMC
May 2015

The world post-STICH: is this a "Game Changer?" A non-invasive cardiologist's perspective-revascularization is the treatment of choice only in patients who fail medical therapy.

Prog Cardiovasc Dis 2013 Mar-Apr;55(5):466-9

Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH, USA.

The optimal management for ischemic cardiomyopathy has been a clinical conundrum for years. Until the publication of the Surgical Treatment of Ischemic Cardiac Heart Failure (STICH) trial, recommendations have been primarily based upon expert opinion, retrospective literature, and clinical anecdotes. However, medical and device management have matured significantly in an era where surgical morbidity and mortality remain significant for coronary bypass grafting in the setting of severe left ventricular dysfunction. For the first time in years, there now exists a landmark prospective randomized clinical trial that addresses the role of coronary bypass surgery as an initial strategy for ischemic cardiomyopathy. Although many interpretations of STICH exist, the neutral results of STICH should reassure clinicians that a strategy of initiating and optimizing medical therapy and deferring surgical revascularization for ischemic cardiomyopathy in "STICH-like patients" is effective, safe, and tested.
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http://dx.doi.org/10.1016/j.pcad.2012.10.014DOI Listing
May 2013

Republished: pathogenesis and diagnosis of myocarditis.

Postgrad Med J 2012 Sep;88(1043):539-44

Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.

Acute myocarditis is an inflammatory disease of the heart muscle that may progress to dilated cardiomyopathy and chronic heart failure. A number of factors including the sex hormone testosterone, components of innate immunity, and profibrotic cytokines have been identified in animal models as important pathogenic mechanisms that increase inflammation and susceptibility to chronic dilated cardiomyopathy. The clinical presentation of acute myocarditis is non-specific and mimics more common causes of heart failure and arrhythmias. Suspected myocarditis is currently confirmed using advanced non-invasive imaging and histopathologic examination of heart tissue. However, the diverse presentations of myocarditis and the lack of widely available, safe, and accurate non-invasive diagnostic tests remain major obstacles to early diagnosis and population based research. Recent advances in the understanding of disease pathogenesis described in this review should lead to more accurate diagnostic algorithms and non-invasive tests.
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http://dx.doi.org/10.1136/postgradmedj-2012-301686repDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5813801PMC
September 2012

Pathogenesis and diagnosis of myocarditis.

Heart 2012 Jun 22;98(11):835-40. Epub 2012 Mar 22.

Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.

Acute myocarditis is an inflammatory disease of the heart muscle that may progress to dilated cardiomyopathy and chronic heart failure. A number of factors including the sex hormone testosterone, components of innate immunity, and profibrotic cytokines have been identified in animal models as important pathogenic mechanisms that increase inflammation and susceptibility to chronic dilated cardiomyopathy. The clinical presentation of acute myocarditis is non-specific and mimics more common causes of heart failure and arrhythmias. Suspected myocarditis is currently confirmed using advanced non-invasive imaging and histopathologic examination of heart tissue. However, the diverse presentations of myocarditis and the lack of widely available, safe, and accurate non-invasive diagnostic tests remain major obstacles to early diagnosis and population based research. Recent advances in the understanding of disease pathogenesis described in this review should lead to more accurate diagnostic algorithms and non-invasive tests.
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http://dx.doi.org/10.1136/heartjnl-2012-301686DOI Listing
June 2012
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