Publications by authors named "Erika D Feller"

21 Publications

  • Page 1 of 1

Higher levels of allograft injury in black patients early after heart transplantation.

J Heart Lung Transplant 2021 Dec 23. Epub 2021 Dec 23.

Genomic Research Alliance for Transplantation (GRAfT), Bethesda, Maryland; Laborarory of Applied Precision Omics (APO), Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland; Department of Medicine, Stanford University School of Medicine, Palo Alto, California. Electronic address:

Black patients suffer higher rates of antibody-mediated rejection and have worse long-term graft survival after heart transplantation. Donor-derived cell free DNA (ddcfDNA) is released into the blood following allograft injury. This study analyzed %ddcfDNA in 63 heart transplant recipients categorized by Black and non-Black race, during the first 200 days after transplant. Immediately after transplant, %ddcfDNA was higher for Black patients (mean [SE]: 8.3% [1.3%] vs 3.2% [1.2%], p = 0.001). In the first week post-transplant, the rate of decay in %ddcfDNA was similar (0.7% [0.68] vs 0.7% [0.11], p = 0.78), and values declined in both groups to a comparable plateau at 7 days post-transplant (0.46% [0.03] vs 0.45% [0.04], p = 0.78). The proportion of Black patients experiencing AMR was higher than non-Black patients (21% vs 9% [hazard ratio of 2.61 [95% confidence interval: 0.651-10.43], p = 0.18). Black patients were more likely to receive a race mismatched organ than non-Black patients (69% vs 35%, p = 0.01), which may explain the higher levels of early allograft injury.
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http://dx.doi.org/10.1016/j.healun.2021.12.006DOI Listing
December 2021

Time in Therapeutic Range Significantly Impacts Survival and Adverse Events in Destination Therapy Patients.

ASAIO J 2022 Jan;68(1):14-20

University of California San Francisco, San Francisco, California.

The study aim was to examine the impact time in therapeutic range (TTR, International Normalized Ratio [INR] 2.0-3.0) has on survival and adverse events in patients receiving the HeartWare HVAD System in the ENDURANCE and ENDURANCE Supplemental Trials. Evaluable subjects (n = 495) had >1 INR value recorded 1-24 months postimplant and were categorized as: low TTR (10-39%), moderate TTR (40-69%), and high TTR (≥70%). Baseline characteristics, adverse events, and survival were analyzed. Low TTR patients experienced higher rates of major bleeding (1.69 vs. 0.54 events per patient year [EPPY]; p < 0.001), GI bleeding (1.22 vs. 0.38 EPPY; p < 0.001), stroke (0.47 vs. 0.17 EPPY; p < 0.001), thrombus requiring exchange (0.05 vs. 0.01 EPPY; p = 0.02), infection (1.44 vs. 0.69 EPPY; p < 0.001), and renal dysfunction (0.23 vs. 0.05 EPPY; p < 0.001) compared with high TTR. Moderate TTR had higher rates of major bleeding (0.75 vs. 0.54 EPPY; p < 0.001), thrombus requiring exchange (0.05 vs. 0.01 EPPY; p = 0.007), cardiac arrhythmia (0.32 vs. 0.24 EPPY; p = 0.04), and infection (0.90 vs. 0.69 EPPY; p = 0.001) compared with high TTR. Two year survival was greater among moderate and high versus low cohorts (Log-rank p = 0.001). The significant reduction in morbidity and mortality in destination therapy (DT) HVAD patients with well-controlled TTR (≥70%) emphasizes the importance of vigilant anticoagulation management.
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http://dx.doi.org/10.1097/MAT.0000000000001572DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8700308PMC
January 2022

Comparison of two individualized antithrombotic protocols in HeartWare HVAD recipients.

Artif Organs 2022 Jan 1;46(1):117-127. Epub 2021 Sep 1.

Division of Cardiology, Department of Medicine, University of Maryland Medical Center, Baltimore, MD, USA.

We previously reported low rates of pump thrombosis and hemorrhagic stroke, but increased bleeding, under our original antithrombosis protocol (P1) in HeartWare recipients. We designed and implemented a revised protocol (P2) to reduce complexity and bleeding. Thrombelastography and PFA-100 guide antiplatelet titration. Goals for P2 were altered to decrease antiplatelet use and anticoagulation intensity. We compared the incidence and rates of gastrointestinal bleeding (GIB), embolic (eCVA) and hemorrhagic (hCVA) stroke, pump thrombosis (PT), and total bleeding (GIB+hCVA), total thrombosis (eCVA+PT), and total events between P1 and P2. Laboratory and medication data were assessed. Patients with and without hemocompatibility-related adverse events (HRAEs) were compared. The study included 123 patients (P1: 65; P2: 58). GIB rate decreased (P1: 0.66; P2 0.30 EPPY, P = .003). CVA rates and incidence were statistically similar, although hCVA incidence increased (P1: 3%; P2: 12%, P = .06). Incidence (P1: 3%; P2: 16%, P = .02) and rate (P1: 0.03; P2: 0.12 EPPY, P = .08) of PT increased. Incidence and rate of overall HRAEs and thrombotic events were similar, while bleeding rate decreased (P1: 0.69; P2: 0.40 EPPY, P = .02). Twelve-month medication burden decreased. Compared to non-HRAE patients, patients with bleeding HRAEs had more antiplatelet and pentoxifylline use, but less statin use; and lower PFAs. Patients with thrombotic HRAEs had less dual antiplatelet use, lower INRs, R-times, and PFA-ADP values. A revised antithrombotic protocol decreased GIB and overall hemorrhagic HRAE rate and medication burden. Unfortunately, PT increased. Non-HRAE and HRAE patients differed in anticoagulation and antiplatelet intensity. These differences will guide the revision of P2.
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http://dx.doi.org/10.1111/aor.14055DOI Listing
January 2022

Minimally Invasive Left Ventricular Assist Device Insertion Facilitates Subsequent Heart Transplant.

Innovations (Phila) 2021 Mar-Apr;16(2):157-162. Epub 2021 Jan 7.

12264 Department of Surgery, Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.

Objective: We have observed that minimally invasive left ventricular assist device (LVAD) insertion leads to more facile re-entry and easier cardiac transplantation. We hypothesize minimally invasive LVAD implantation results in improved outcomes at the time of subsequent heart transplant.

Methods: All adults undergoing cardiac transplantation between October 2015 and March 2019 at our institution were retrospectively reviewed. Those bridged to transplantation with a HeartWare HVAD were identified and divided into 2 cohorts based upon the surgical approach: those who underwent HVAD placement by conventional sternotomy versus minimally invasive insertion via lateral thoracotomy and hemisternotomy (LTHS). Patient demographics, as well as perioperative transplant outcomes, including survival, length of stay (LOS), blood utilization, ischemic time, bypass time, and postoperative extracorporeal membrane oxygenation (ECMO) were compared between cohorts.

Results: Forty-two patients were bridged to heart transplant with a HVAD implanted via either sternotomy ( = 22) or LTHS technique ( = 20). Demographics were similar between groups. There was 1 predischarge death in the sternotomy group and none in the LTHS group. Body surface area, cardiopulmonary bypass time, ischemic time, ECMO utilization, and reoperation for bleeding were similar. Red blood cell units transfused were significantly lower in the LTHS cohort (3.0 [1.0-5.0] vs 6.0 [2.5-10.0] = 0.046). The LTHS cohort had a significantly shorter hospital LOS (12.0 [11.0-28.0] vs 22.5 [15.7-41.7] = 0.022) with a trend toward shorter intensive care unit LOS (6.0 [5.0-10.5] vs 11.0 [6.0-21.5] days = 0.057).

Conclusions: Minimally invasive HVAD implantation improves outcomes at subsequent heart transplantation, resulting in shorter LOS and less red cell transfusion. Larger multi-institutional studies are necessary to validate these findings.
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http://dx.doi.org/10.1177/1556984520980409DOI Listing
November 2021

A Minimally Invasive Approach to Left Ventricular Assist Device Insertion Facilitates Subsequent Explant.

Innovations (Phila) 2021 Jan-Feb;16(1):104-107. Epub 2020 Nov 18.

6595 Division of Cardiac Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA.

A minimally invasive approach to left ventricular assist device (LVAD) insertion may benefit patients at the time of implant, but whether the approach to LVAD insertion influences the outcome of subsequent cardiovascular reoperations is unknown. Here we present the case of a 50-year-old male who underwent LVAD insertion through a minimally invasive approach and subsequently had left ventricular recovery. LVAD explant was performed without the use of any blood products or inotropic support. This case demonstrates that a minimally invasive approach to LVAD insertion may also facilitate subsequent device explant.
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http://dx.doi.org/10.1177/1556984520974001DOI Listing
November 2021

Outcomes with temporary mechanical circulatory support before minimally invasive centrifugal left ventricular assist device.

J Card Surg 2020 Jul 24;35(7):1539-1547. Epub 2020 Jun 24.

Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Maryland.

Background: Despite improved survival and morbidity after durable left ventricular assist device (dLVAD), outcomes for cardiogenic shock patients are suboptimal. Temporary mechanical circulatory support (tMCS) can permit optimization before dLVAD. Excellent outcomes have been observed using minimally-invasive dLVAD implantation. However, some feel tMCS contraindicates this approach. To evaluate whether left thoracotomy/hemisternotomy (LTHS) dLVAD placement is safe in this setting, we compared patients who did and did not require tMCS.

Methods: Outcomes for patients receiving dLVADs via LTHS were compared among those bridged with extracorporeal membrane oxygenation (ECMO), intra-aortic balloon pump (IABP), or no tMCS. We evaluated demographics, comorbidities, laboratory and hemodynamic data, and intraoperative and postoperative outcomes.

Results: Eighty-three patients underwent LTHS dLVAD placement. Fifty did not require tMCS, while 22 (26%) required IABP, and 11 (13%) ECMO. Non-tMCS patients were primarily Intermacs 3 (56%), while IABP recipients were mainly Intermacs 2 (45%). All patients with ECMO were Intermacs 1. Patients with tMCS had worse end-organ function. Operative outcomes were similar except more concomitant procedures and red-cell transfusions in patients with ECMO. Intensive care unit and hospital length of stay and inotrope duration were also similar. There were no differences in bleeding, stroke, and infection rates. Three- and 12-month survival were: no tMCS: 94%, 86%; IABP: 100%, 88%; and ECMO: 81%, 81% (P = .45).

Conclusions: Patients with cardiogenic shock can safely undergo LTHS dLVAD implantation after stabilization with ECMO or IABP. Outcomes and complications in these patients were comparable to a less severely ill cohort without tMCS.
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http://dx.doi.org/10.1111/jocs.14655DOI Listing
July 2020

The Heartware Lavare Cycle: A Cautionary Tale.

ASAIO J 2020 Sep/Oct;66(9):e114-e116

Division of Cardiology, Department of Medicine, University of Maryland Medical Center, Baltimore, Maryland.

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http://dx.doi.org/10.1097/MAT.0000000000001161DOI Listing
March 2021

When It Rains It Pours.

Authors:
Erika D Feller

ASAIO J 2019 08;65(6):535-536

From the Adult Heart Failure & Cardiothoracic Transplant Program, University of Maryland Medical Center, Baltimore, Maryland.

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http://dx.doi.org/10.1097/MAT.0000000000001056DOI Listing
August 2019

FDG PET/CT for Early Detection and Localization of Left Ventricular Assist Device Infection: Impact on Patient Management and Outcome.

JACC Cardiovasc Imaging 2019 04 14;12(4):722-729. Epub 2018 Mar 14.

Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland. Electronic address:

Objectives: The feasibility of F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) for the diagnosis of left ventricular assist device (LVAD) infection has been demonstrated. Beyond the diagnoses of LVAD infection, the authors hypothesized that the pattern and site of the infection along its various components may significantly impact clinical management and patient outcome.

Background: In patients with end-stage heart failure, the clinical use of LVAD for destination therapy is on the rise, accompanied by a higher prevalence of infections and serious complications.

Methods: FDG PET/CT was performed in 35 heart failure patients with LVAD, 24 with and 11 without clinical suspicion of infection. Microbiology and/or clinical follow-up were used as the final diagnosis standard. Survival rates were compared in patients with and without FDG evidence of infection, and in relation to peripheral (exit wound site or driveline) versus central (cannula or pump) device infection.

Results: Of 35 patients, 28 (80%) showed metabolic evidence of LVAD infection: 5 limited to the periphery and 23 with extension to the central components of the device. The remaining 7 patients showed no metabolic evidence of infection, which was confirmed by microbiology and clinical follow-up. When CT images were interpreted independently from the FDG PET and clinical information, only 4 of 35 (11%) suggested the possibility of infection. Fourteen of 28 (50%) infected patients died during a mean of 23 months of follow-up after the diagnosis by FDG PET/CT: 12 (86%) with central infection and only 2 with peripheral infection. By contrast, none of the 7 (0%) noninfected patients died (p = 0.03).

Conclusions: FDG PET/CT is a useful technique for identifying LVAD infection and determining the site and pattern of the infection. The latter has clinical management and patient outcome implications.
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http://dx.doi.org/10.1016/j.jcmg.2018.01.024DOI Listing
April 2019

Individualized Antithrombotic Therapy in Heartware HVAD Recipients.

ASAIO J 2019 01;65(1):29-35

Division of Cardiology, Department of Medicine.

There are no evidence-based guidelines for antithrombotic therapy in left ventricular assist device patients. We evaluated the efficacy of a multi-agent, test-guided protocol, which remained consistent throughout our use of the Heartware HVAD. Thrombelastography and platelet function analyzer (PFA)-100 guide antiplatelet titration. Goals are normal kaolin thrombelastography maximum amplitude and prolonged PFA-100. We analyzed incidence and rates of nonprocedural bleeding, stroke, and pump thrombosis for all 81 primary Heartware left ventricular assist devices implanted since 2011. For each event, we examined whether each test was within goal range. We also compared medication burden and dosage between patients with and without events. Pump thrombosis and hemorrhagic stroke each occurred in two patients (2.5%; 0.03 events/patient-year [EPPY]), and ischemic stroke in six (7.4%; 0.10 EPPY). Nonprocedural bleeding occurred 75 times in 34 patients (42%; 1.24 EPPY), primarily gastrointestinal (28%; 0.66 EPPY). Subtherapeutic international normalized ratio (INR) was the most common at thrombotic events; supratherapeutic partial thromboplastin time, international normalized ratio (INR), and PFA-adenosine diphosphate (ADP) were common at bleeding events. Medication burden and dosage were lower in patients with events than in stable patients. Protocol-guided antithrombotic therapy resulted in low rates of pump thrombosis and hemorrhagic stroke. Ischemic stroke and gastrointestinal bleeding rates were higher than in a comparable HVAD population. Optimization of our protocol to decrease its complexity and to reduce bleeding is underway.
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http://dx.doi.org/10.1097/MAT.0000000000000751DOI Listing
January 2019

Quantitative Assessment of Inflow Malposition in Two Continuous-Flow Left Ventricular Assist Devices.

Ann Thorac Surg 2018 05 3;105(5):1377-1383. Epub 2018 Jan 3.

Department of Surgery, Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Maryland.

Background: We previously investigated preoperative variables associated with qualitative inflow cannula malposition in the HeartMate II (Thoratec-Abbott, Abbott Park, IL) continuous-flow left ventricular assist device. In this report, we assess inflow cannula malposition quantitatively in recipients of both the HeartMate II and the HeartWare (Medtronic-HeartWare, Minneapolis, MN) and examine its association with device thrombosis.

Methods: Malposition was quantified based on angular deviation from a hypothetic ideal inflow cannula position in two orthogonal computed tomography imaging planes. Ideal position lies on a line from the apex to the center of the mitral valve. Positive anterior plane angulation indicates deviation toward the superior free wall; negative, toward the inferior wall. Positive lateral plane angulation indicates deviation toward the septum; negative, toward the lateral wall. Device thrombosis was assessed based on clinical criteria.

Results: Fifty-four HeartMate II patients and 68 HeartWare patients were analyzed. Inflow cannula deviation was significantly higher for HeartMate II than for HeartWare (anterior plane angle 36.7 ± 16.8 versus -18.7 ± 11.6 degrees, p < 0.001; lateral plane angle 23.7 ± 20.1 versus 0.2 ± 15.0 degrees, p < 0.001. Pump thrombosis occurred in 31% of HeartMate II patients and 2.9% of HeartWare patients (p < 0.001). In a multivariate model, HeartMate II and increasing inflow cannula deviation toward the septum were associated with higher thrombosis risk (odds ratio 1.35 per 10-degree increase).

Conclusions: We found distinct device-dependent differences in inflow cannula positioning and thrombosis, with HeartWare showing both less malposition and less thrombosis. Malposition toward the ventricular septum may contribute to pump thrombosis through a vicious cycle of suction events, low flow, and speed reduction.
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http://dx.doi.org/10.1016/j.athoracsur.2017.12.004DOI Listing
May 2018

Systemic Inflammatory Response Syndrome After Contentious-Flow Left Ventricular Assist Device Implantation and Change in Platelet Mitochondrial Membrane Potential.

J Card Fail 2015 Jul 25;21(7):564-71. Epub 2015 Apr 25.

Department of Surgery, Artificial Organs Laboratory, University of Maryland School of Medicine, Baltimore, Maryland. Electronic address:

Background: The objective of this study was to investigate the change of platelet function and platelet mitochondrial membrane potential in contentious-flow left ventricular assist device (CF-LVAD)-implanted heart failure (HF) patients with or without systemic inflammatory response syndrome (SIRS).

Methods And Results: We recruited 31 CF-LVAD patients (16 SIRS and 15 non-SIRS) and 11 healthy volunteers as control. Pre- and post-implantation blood samples were collected. We used PFA-100 to test platelet functionality. Mitochondrial potential-sensitive dye was used to detect platelet dysfunction (mitochondrial membrane potential; ΔΨm) via flow cytometry. The percentage of depolarized-ΔΨm platelets was found to be a preexisting condition in all HF patients before CF-LVAD implantation compared with control subjects (10.3 ± 6.3% vs 2.8 ± 2.2%; P < .001). As evident from the PFA-100 test, the HF patients who developed SIRS after CF-LVAD implantation had significantly more qualitative platelet defects and thrombocytopathies compared with baseline. After implantation, the depolarized platelets in the SIRS patients increased by 2-fold compared with baseline (18.2 ± 8.4% vs 9.0 ± 6.6%; P < .01); whereas no change was noticed in the non-SIRS patients (10.9 ± 6.2% vs 11.7 ± 5.8%; P = .75).

Conclusions: We identified that platelet function and mitochondrial damage were enhanced in CF-LVAD patients with SIRS. Our findings suggest that depolarization of mitochondrial membrane potential is associated with SIRS after CF-LVAD implantation surgery.
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http://dx.doi.org/10.1016/j.cardfail.2015.04.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4499008PMC
July 2015

Comparison of intraplatelet reactive oxygen species, mitochondrial damage, and platelet apoptosis after implantation of three continuous flow left ventricular assist devices: HeartMate II, Jarvik 2000, and HeartWare.

ASAIO J 2015 May-Jun;61(3):244-52

From the *Department of Surgery, Artificial Organs Laboratory, University of Maryland School of Medicine, Baltimore, Maryland; †Department of Clinical Engineering, University of Maryland Medical Center, Baltimore, Maryland; and ‡Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland.

Differences in device design may have an effect on platelet damage and associated clinical complications. We aimed to compare device-specific platelet functionality in 26 heart failure patients supported with three continuous-flow left ventricular assist devices: HeartMate II (n = 8), Jarvik 2000 (n = 9), and HeartWare (n = 9). Intraplatelet reactive oxygen species (ROS) generation, mitochondrial damage, and platelet apoptosis were compared between device types before and after the implantation at every week up to 1 month. Overall, the baseline characteristics, demographics, routine laboratory values were comparable between the three device groups. Intraplatelet ROS, mitochondrial damage, and platelet apoptosis significantly elevated in the HeartWare group in comparison with the other two device groups after implantation. The major bleeding, infections, systemic inflammatory response syndrome, and right ventricular failure were found to be more common among the HeartWare group than others. Intraplatelet ROS and platelet damage levels were returned to baseline in both the HeartMate II and the Jarvik groups, whereas in HeartWare group they remained elevated. The patients with the Jarvik and the HeartMate II experienced less clinical complications and the platelet functionality is not compromised by these devices. Data from this study suggests that the continuous-flow left ventricular assist devices design may exert different effects on platelet function.
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http://dx.doi.org/10.1097/MAT.0000000000000208DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7350936PMC
February 2016

Intraplatelet reactive oxygen species, mitochondrial damage and platelet apoptosis augment non-surgical bleeding in heart failure patients supported by continuous-flow left ventricular assist device.

Platelets 2015 28;26(6):536-44. Epub 2014 Aug 28.

Department of Surgery, Artificial Organs Laboratory, University of Maryland School of Medicine , Baltimore, Maryland , USA .

Non-surgical bleeding (NSB) is the most common clinical complication among heart failure (HF) patients supported by continuous-flow left ventricular assist devices (CF-LVADs). Understanding the role of platelet functionality contributing to NSB after CF-LVAD implantation is crucial for prevention and management of this adverse event. The aim of this study was to examine the role of intraplatelet reactive oxygen species (ROS) and platelet damage on the incidence of bleeding events after CF-LVAD implantation in HF patients. We recruited 25 HF patients implanted with CF-LVADs and 11 healthy volunteers as the control. Intraplatelet ROS generation, platelet mitochondrial damage and platelet apoptosis were quantified by flow cytometry. Among 25 patients, 8 patients developed non-surgical bleeding within one month after CF-LVAD implantation. Intraplatelet ROS, depolarized and apoptotic platelet were found to be pre-existing conditions in all baseline samples of the 25 HF patients when compared to the healthy volunteers. There was no significant difference in the levels of ROS between the non-bleeder and the bleeder groups prior to CF-LVAD implantation, although we noticed 2-fold and 1.5-fold rise in depolarized and apoptotic platelets, respectively, in the bleeder group compared to those in the non-bleeder group. Post implant levels of intraplatelet ROS, depolarized and apoptotic platelets increased and remained elevated in the bleeder group, whereas periodic decreases were noticed in the non-bleeder group, suggesting the potential role of platelet damage on bleeding incidence. ROS generation after CF-LVAD implantation positively associated with platelet apoptosis (ρ = 0.4263, p = 0.0023) and depolarized platelets (ρ = 0.4774, p = 0.0002), especially the latter. In conclusion, elevated intraplatelet ROS and platelet damage may be linked to the NSB among HF patients supported by CF-LVAD. These results provide mechanistic insights into the bleeding complication in patients with CF-LVAD support.
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http://dx.doi.org/10.3109/09537104.2014.948840DOI Listing
May 2016

FDG PET/CT imaging for LVAD associated infections.

JACC Cardiovasc Imaging 2014 Aug;7(8):839-42

Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland. Electronic address:

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http://dx.doi.org/10.1016/j.jcmg.2014.04.013DOI Listing
August 2014

University of Maryland surgical experience with the Jarvik 2000 axial flow ventricular assist device.

Ann Thorac Surg 2012 Jan 23;93(1):133-40. Epub 2011 Nov 23.

Division of Clinical Engineering, University of Maryland Medical Center, Baltimore, Maryland 21201, USA.

Background: The Jarvik 2000, an axial flow ventricular assist device (VAD), is currently under investigation for bridge to transplant (BTT) indications. The principal advantage of the Jarvik device is intraventricular pump placement. This eliminates the inflow cannula and pump pocket and allows for uncomplicated left ventricular implantation without sternotomy. Here we describe the evolution of our surgical implantation and explantation technique.

Methods: Data for all patients undergoing implantation of a left VAD (LVAD) (n=35) at the University of Maryland between September 2002 and September 2010 were retrospectively reviewed. Preoperative patient demographics and clinical status and operative technique and outcomes were reviewed.

Results: A simple technique for enclosing the pump and outflow graft greatly simplifies the explantation procedure and reduces the risk of lung adhesions and injury. Off-pump implantation reduces operative time and intraoperative red cell transfusions but carries a risk of incomplete ventricular coring, which may precipitate pump thrombosis. The benefits of the left thoracotomy approach were seen in the reduced need for intraoperative red cell transfusion and reduced total intensive care unit (ICU) stay for patients who had undergone previous sternotomy.

Conclusions: The Jarvik 2000 has several distinctive features that simplify surgical management and permit flexible application in an expanded range of candidates for LVAD implantation, particularly in patients who have undergone previous sternotomy.
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http://dx.doi.org/10.1016/j.athoracsur.2011.09.021DOI Listing
January 2012

Clinical outcomes are similar in pulsatile and nonpulsatile left ventricular assist device recipients.

Ann Thorac Surg 2007 Mar;83(3):1082-8

Division of Cardiology, University of Maryland Medical Center, Baltimore, Maryland 21201, USA.

Background: Despite concerns about the adequacy of support provided by continuous-flow left ventricular assist devices (LVADs), direct comparisons of patient characteristics and outcomes between first-generation pulsatile and second-generation nonpulsatile LVADs are absent. We hypothesized that a nonpulsatile Jarvik 2000 LVAD (Jarvik Heart, Inc, New York, NY) would result in comparable outcomes to those of similarly ill patients implanted with a pulsatile LVAD (Novacor, WorldHeart Inc, Oakland, CA; and HeartMate XVE, Thoratec, Pleasanton, CA).

Methods: We retrospectively compared common pre-LVAD clinical characteristics and indicators of heart failure severity between 13 pulsatile and 14 nonpulsatile LVAD recipients. The outcomes analyzed were either heart transplantation, if the LVAD was intended as a bridge to transplantation, or hospital discharge if the intention was destination therapy.

Results: There was no significant difference between groups in pre-LVAD disease severity indicators. Nonpulsatile LVAD recipients had a significantly smaller body surface area (1.9 +/- 0.2 m2 versus 2.1 +/- 0.2 m2, p = 0.04) and cardiopulmonary bypass time was also significantly shorter (61 +/- 34 minutes versus 110 +/- 49 minutes, p = 0.01). Aside from duration of initial intensive care unit stay (nonpulsatile, 10 +/- 16 days; pulsatile, 14 +/- 11 days; p = 0.02), there was no difference in post-LVAD outcomes: 10 of 14 nonpulsatile and 8 of 13 pulsatile LVAD patients achieved the combined end point (p = 0.69).

Conclusions: Similarly ill congestive heart failure patients benefited equally well from either a nonpulsatile or a pulsatile LVAD. This may support an expanded role for nonpulsatile LVADs in the treatment of severe heart failure.
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http://dx.doi.org/10.1016/j.athoracsur.2006.10.034DOI Listing
March 2007

Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure.

J Am Coll Cardiol 2007 Feb 26;49(6):675-83. Epub 2007 Jan 26.

Midwest Heart Foundation, Edward Heart Hospital, Lombard, Illinois 60566, USA.

Objectives: This study was designed to compare the safety and efficacy of veno-venous ultrafiltration and standard intravenous diuretic therapy for hypervolemic heart failure (HF) patients.

Background: Early ultrafiltration may be an alternative to intravenous diuretics in patients with decompensated HF and volume overload.

Methods: Patients hospitalized for HF with > or =2 signs of hypervolemia were randomized to ultrafiltration or intravenous diuretics. Primary end points were weight loss and dyspnea assessment at 48 h after randomization. Secondary end points included net fluid loss at 48 h, functional capacity, HF rehospitalizations, and unscheduled visits in 90 days. Safety end points included changes in renal function, electrolytes, and blood pressure.

Results: Two hundred patients (63 +/- 15 years, 69% men, 71% ejection fraction < or =40%) were randomized to ultrafiltration or intravenous diuretics. At 48 h, weight (5.0 +/- 3.1 kg vs. 3.1 +/- 3.5 kg; p = 0.001) and net fluid loss (4.6 vs. 3.3 l; p = 0.001) were greater in the ultrafiltration group. Dyspnea scores were similar. At 90 days, the ultrafiltration group had fewer patients rehospitalized for HF (16 of 89 [18%] vs. 28 of 87 [32%]; p = 0.037), HF rehospitalizations (0.22 +/- 0.54 vs. 0.46 +/- 0.76; p = 0.022), rehospitalization days (1.4 +/- 4.2 vs. 3.8 +/- 8.5; p = 0.022) per patient, and unscheduled visits (14 of 65 [21%] vs. 29 of 66 [44%]; p = 0.009). No serum creatinine differences occurred between groups. Nine deaths occurred in the ultrafiltration group and 11 in the diuretics group.

Conclusions: In decompensated HF, ultrafiltration safely produces greater weight and fluid loss than intravenous diuretics, reduces 90-day resource utilization for HF, and is an effective alternative therapy. (The UNLOAD trial; http://clinicaltrials.gov/ct/show/NCT00124137?order=1; NCT00124137).
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http://dx.doi.org/10.1016/j.jacc.2006.07.073DOI Listing
February 2007

Acute congestive heart failure in the emergency department.

Cardiol Clin 2006 Feb;24(1):115-23, vii

Division of Emergency Medicine, Department of Medicine, University of Maryland School of Medicine, 110 South Paca Street, Sixth Floor, Suite 200, Baltimore, MD 21201, USA.

Acute heart failure and cardiogenic pulmonary edema is a common cause of respiratory distress among patients presenting to the emergency department. The emergency department is frequently the primary entry point into the health care system for these patients and is the site of initial stabilization, evaluation, and management of the patient.Emergency physicians, alongside cardiologists, play a critical role as these patients are treated in the emergency department and transferred to the cardiac ICU. The approach to the critically ill patient who has heart failure should be multidisciplinary and involve the emergency physician and the cardiologist who will care for the patient.
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http://dx.doi.org/10.1016/j.ccl.2005.09.004DOI Listing
February 2006

Allograft inflammatory factor-1 expression correlates with cardiac rejection and development of cardiac allograft vasculopathy.

Circulation 2002 Oct;106(17):2218-23

Department of Physiology, Cardiovascular Research Group, Temple University School of Medicine, Philadelphia, Pa. 19140, USA.

Background: Standard morphological features of endomyocardial biopsy specimens do not necessarily correlate with the efficacy of immunotherapy or development of cardiac allograft vasculopathy (CAV). We hypothesized that expression of allograft inflammatory factor-1 (AIF-1), a cytokine-inducible, calcium-binding protein associated with vascular smooth muscle cell proliferation, would be associated with allograft rejection and development of CAV.

Methods And Results: A total of 157 endomyocardial biopsy specimens from 26 patients with heart transplants were examined for expression of AIF-1 mRNA by semiquantitative reverse transcription-polymerase chain reaction. A significant relation was found between the International Society for Heart and Lung Transplantation rejection grade and expression of AIF-1 (P<0.001). The calculated odds ratio indicates that a biopsy has 2.5 times the chance of AIF-1 expression per grade of rejection. The relative concentrations of AIF-1 and GAPDH mRNA were calculated and the resulting ratios indicated that the amount of AIF-1 mRNA expression is relative to the rejection grade (P<0.02). In grade 1 biopsy specimens, AIF-1 was localized to infiltrating immune cells. In grade 3 biopsy specimens, AIF-1 was observed in immune cells and myocytes. AIF-1 is expressed in vascular and immune cells in coronary arteries with CAV, and persistent expression of AIF-1 in the allograft correlates with development of CAV (P<0.002).

Conclusions: Expression of AIF-1 in cardiac allografts correlates with rejection, and the amount of AIF-1 expressed correlates with the severity of rejection. AIF-1 is expressed in coronary arteries with CAV, and persistent expression of AIF-1 in the cardiac allograft is associated with development of CAV.
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http://dx.doi.org/10.1161/01.cir.0000035652.71915.00DOI Listing
October 2002
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