Publications by authors named "Gabriel T Sayer"

18 Publications

  • Page 1 of 1

Levels of Trimethylamine N-Oxide Remain Elevated Long Term After Left Ventricular Assist Device and Heart Transplantation and Are Independent From Measures of Inflammation and Gut Dysbiosis.

Circ Heart Fail 2021 Jun 15;14(6):e007909. Epub 2021 Jun 15.

Department of Epidemiology, Mailman School of Public Health (S.M., R.T.D.), Columbia University Irving Medical Center, New York, NY.

Background: Trimethylamine N-oxide (TMAO)-a gut-derived metabolite-is elevated in heart failure (HF) and linked to poor prognosis. We investigated variations in TMAO in HF, left ventricular assist device (LVAD), and heart transplant (HT) and assessed its relation with inflammation, endotoxemia, oxidative stress, and gut dysbiosis.

Methods: We enrolled 341 patients. TMAO, CRP (C-reactive protein), IL (interleukin)-6, TNF-α (tumor necrosis factor alpha), ET-1 (endothelin-1), adiponectin, lipopolysaccharide, soluble CD14, and isoprostane were measured in 611 blood samples in HF (New York Heart Association class I-IV) and at multiple time points post-LVAD and post-HT. Gut microbiota were assessed via 16S rRNA sequencing among 327 stool samples. Multivariable regression models were used to assess the relationship between TMAO and (1) New York Heart Association class; (2) pre- versus post-LVAD or post-HT; (3) biomarkers of inflammation, endotoxemia, oxidative stress, and microbial diversity.

Results: ln-TMAO was lower among HF New York Heart Association class I (1.23 [95% CI, 0.52-1.94] µM) versus either class II, III, or IV (1.99 [95% CI, 1.68-2.30], 1.97 [95% CI, 1.71-2.24], and 2.09 [95% CI, 1.83-2.34] µM, respectively; all <0.05). In comparison to class II-IV, ln-TMAO was lower 1 month post-LVAD (1.58 [95% CI, 1.32-1.83] µM) and 1 week and 1 month post-HT (0.97 [95% CI, 0.60-1.35] and 1.36 [95% CI, 1.01-1.70] µM). ln-TMAO levels in long-term LVAD (>6 months: 1.99 [95% CI, 1.76-2.22] µM) and HT (>6 months: 1.86 [95% CI, 1.66-2.05] µM) were not different from symptomatic HF. After multivariable adjustments, TMAO was not associated with biomarkers of inflammation, endotoxemia, oxidative stress, or microbial diversity.

Conclusions: TMAO levels are increased in symptomatic HF patients and remain elevated long term after LVAD and HT. TMAO levels were independent from measures of inflammation, endotoxemia, oxidative stress, and gut dysbiosis.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.120.007909DOI Listing
June 2021

Right Ventricular Pressure-Volume Analysis During Left Ventricular Assist Device Speed Optimization Studies: Insights Into Interventricular Interactions and Right Ventricular Failure.

J Card Fail 2021 May 12. Epub 2021 May 12.

Division of Cardiology, Columbia University Medical Center-New York Presbyterian Hospital in New York, New York, New York; Cardiovascular Research Foundation in New York, New York.

Background: Interventricular interaction, which refers to the impact of left ventricular (LV) function on right ventricular (RV) function and vice versa, has been implicated in the pathogenesis of RV failure in LV assist device (LVAD) recipients. We sought to understand more about interventricular interaction by quantifying changes in the RV systolic and diastolic function with varying LVAD speeds.

Methods And Results: Four patients (ages 22-69 years, 75% male, and 25% with ischemic cardiomyopathy) underwent a protocolized hemodynamic ramp test within 12 months of LVAD implantation where RV pressure-volume loops were recorded with a conductance catheter. The end-systolic PV relationship and end-diastolic PV relationship were compared using the V and V indices (volumes at which end-systolic PV relationship and end-diastolic PV relationship reach a pressure of 20 and 10 mm Hg, respectively). The ∆V and ∆V refer to the change in V and V from the minimum to maximum LVAD speeds. RV PV loops demonstrated variable changes in systolic and diastolic function with increasing LVAD speed. The end-systolic PV relationship changed in 1 patient (patient 2, ∆V = 23.5 mL), reflecting a decrease in systolic function with increased speed, and was unchanged in 3 patients (average ∆V = 7.4 mL). The end-diastolic PV relationship changed with increasing speed in 3 of 4 patients (average ∆V = 12.5 mL), indicating an increase in ventricular compliance, and remained unchanged in one participant (patient 1; ∆V = 4.0 mL).

Conclusions: Interventricular interaction can improve RV compliance and impair systolic function, but the overall effect on RV performance in this pilot investigation is heterogeneous. Further research is required to understand which patient characteristics and hemodynamic parameters influence the net impact of interventricular interaction.
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http://dx.doi.org/10.1016/j.cardfail.2021.04.019DOI Listing
May 2021

Association of preoperative infections, nasal Staphylococcus aureus colonization and gut microbiota with left ventricular assist device outcomes.

Eur J Heart Fail 2021 May 8. Epub 2021 May 8.

Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA.

Aims: Infections are common following left ventricular assist device (LVAD) implantation and predict adverse events. Infections are frequent prior to LVAD implantation although their impact on postoperative outcomes remains unknown. Gut and nasal microbial imbalance may predispose to mucosal colonization with pathogens. Herein, we investigated the predictive role of pre-LVAD infections, and explored the association of nasal Staphylococcus aureus (SA) colonization and gut microbiota, on postoperative outcomes.

Methods And Results: Overall, 254 LVAD patients were retrospectively categorized based on pre-LVAD infection status: Group 1, bacterial/fungal bloodstream infection (BSI); Group 2, other bacterial/fungal; Group 3, viral; and Group 4, no infection. In a subset of patients, nasal SA colonization (n = 140) and pre-LVAD stool (n = 25) were analysed using 16S rRNA sequencing. A total of 75 (29%) patients had a pre-LVAD infection [Group 1: 22 (29%); Group 2: 41 (55%); Group 3: 12 (16%)]. Pre-LVAD BSIs were independent predictors of 1-year postoperative mortality and infections [Group 1 vs. 4: hazard ratio (HR) 2.70, P = 0.036 vs. HR 1.8, P = 0.046]. In an unadjusted analysis, pre-LVAD infections other than BSIs, INTERMACS profile ≤2, higher serum creatinine, lower serum albumin and nasal SA colonization were also significantly associated with postoperative infections. Patients with early post-LVAD infections exhibited decreased microbial diversity (P < 0.05).

Conclusions: Pre-LVAD infections are common. BSIs independently predict postoperative mortality and infections. Additional studies are needed to confirm our findings that pre-LVAD SA nasal colonization and gut microbial composition can help stratify patients' risk for infectious complications after LVAD implantation.
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http://dx.doi.org/10.1002/ejhf.2215DOI Listing
May 2021

Extracorporeal photopheresis and its role in heart transplant rejection: prophylaxis and treatment.

Clin Transplant 2021 Apr 29:e14333. Epub 2021 Apr 29.

Division of Cardiology, Department of Medicine, Columbia University, New York, NY, USA.

Heart transplantation is the gold standard therapeutic option for select patients with end-stage heart failure. Unfortunately, successful long-term outcomes of heart transplantation can be hindered by immune-mediated rejection of the cardiac allograft, specifically acute cellular rejection, antibody-mediated rejection, and cardiac allograft vasculopathy. Extracorporeal photopheresis is a cellular immunotherapy that involves the collection and treatment of white blood cells contained in the buffy coat with a photoactive psoralen compound, 8-methoxy psoralen, and subsequent irradiation with ultraviolet A light. This process is thought to cause DNA and RNA crosslinking, ultimately leading to cell destruction. The true mechanism of therapeutic action remains unknown. In the last three decades, extracorporeal photopheresis has shown promising results and is indicated for a variety of conditions. The American Society for Apheresis currently recommends the use of extracorporeal photopheresis for the treatment of cutaneous T-cell lymphoma, scleroderma, psoriasis, pemphigus vulgaris, atopic dermatitis, graft-versus-host disease, Crohn's disease, nephrogenic systemic fibrosis, and solid organ rejection in heart, lung, and liver transplantation. In this review, we aim to explore the proposed effects of extracorporeal photopheresis and to summarize published data on its use as a prophylactic and therapy in heart transplant rejection.
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http://dx.doi.org/10.1111/ctr.14333DOI Listing
April 2021

De Novo Human Leukocyte Antigen Allosensitization in Heartmate 3 Versus Heartmate II Left Ventricular Assist Device Recipients.

ASAIO J 2021 Apr 19. Epub 2021 Apr 19.

From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, New York Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York.

Left ventricular assist devices (LVADs) are associated with the development of antihuman leukocyte antigen (HLA) antibodies, which can create a challenge for future transplantation in these patients. The differential effects of Heartmate 3 (HM3) versus Heartmate II (HMII) on de novo HLA allosensitization remain unknown. Patients who underwent HMII or HM3 implantation and had no prior HLA antibodies by solid-phase assay (Luminex) testing were included in this study. Complement-dependent cytotoxicity (CDC) panel reactive antibody (PRA) levels and Luminex antibody profiles were followed until cardiac transplantation, device explantation, or death. Electronic medical records were reviewed to examine posttransplant outcomes. Thirty-eight HM3 and 34 HMII patients with complete data were followed for 1.5 ± 1.1 years on device support. HM3 and HMII groups had similar age at implant, female gender, ischemic heart failure etiology, bridge strategy at implant, as well as intraoperative and postoperative transfusion requirements. 39.5% of HM3 and 47.1% of HMII patients developed detectable HLA antibodies by Luminex testing (p = 0.516). Development of high-level (mean fluorescence intensity >10,000) antibodies was significantly lower in HM3 than HMII patients (5.3 vs. 20.6%, p = 0.049). CDC PRA testing showed fewer HM3 patients with a positive result (PRA > 0%) than HMII patients (39.4 vs. 70.0%, p = 0.015). Among transplanted patients, those who had developed de novo sensitization on LVAD support showed a trend toward incidence of moderate to severe grade rejection compared with unsensitized patients (23.8 vs. 4.8%, p = 0.078). HM3 is associated with lower risk of de novo HLA sensitization compared with HMII.
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http://dx.doi.org/10.1097/MAT.0000000000001451DOI Listing
April 2021

National outcomes of bridge to multiorgan cardiac transplantation using mechanical circulatory support.

J Thorac Cardiovasc Surg 2021 Feb 5. Epub 2021 Feb 5.

Division of Cardiothoracic Surgery, Department of Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY. Electronic address:

Background: Little is known regarding the profile of patients with multiorgan failure listed for simultaneous cardiac transplantation and secondary organ. In addition, few studies have reported how these patients are bridged with mechanical circulatory support (MCS). In this study, we examined national data of patients listed for multiorgan transplantation and their outcomes after bridging with or without MCS.

Methods: United Network for Organ Sharing data were reviewed for adult multiorgan transplantations from 1986 to 2019. Post-transplant patients and total waitlist listings were examined and stratified according to MCS status. Survival was assessed via Cox regression in the post-transplant cohort and Fine-Gray competing risk regression with transplantation as a competing risk in the waitlist cohort.

Results: There were 4534 waitlist patients for multiorgan transplant during the study period, of whom 2117 received multiorgan transplants. There was no significant difference in post-transplant survival between the MCS types and those without MCS in the whole cohort and heart-kidney subgroup. Fine-Gray competing risk regression showed that patients bridged with extracorporeal membrane oxygenation had significantly greater waitlist mortality compared with those without MCS when controlling for preoperative characteristics (subdistribution hazard ratio, 2.27; 95% confidence interval, 1.48-3.47; P < .001), whereas those bridged with a ventricular assist device had a decreased incidence of death compared with those without MCS (subdistribution hazard ratio, 0.78; 95% confidence interval, 0.63-0.96; P = .017).

Conclusions: MCS, as currently applied, does not appear to compromise the survival of multiorgan heart transplant patients. Waitlist data show that extracorporeal membrane oxygenation patients have profoundly worse survival irrespective of preoperative factors including organ type listed. Survival on the waitlist for multiorgan transplant has improved across device eras.
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http://dx.doi.org/10.1016/j.jtcvs.2021.01.114DOI Listing
February 2021

Safety of reduced anti-thrombotic strategy in patients with HeartMate 3 left ventricular assist device.

J Heart Lung Transplant 2021 Apr 19;40(4):237-240. Epub 2021 Jan 19.

Division of Cardiology, Department of Medicine, New York Presbyterian Hospital, Columbia University, New York City, New York. Electronic address:

There are limited safety data on reduced anti-thrombotic therapy (RT) in patients with HeartMate 3 (HM3) left ventricular assist device (LVAD). We conducted a single-center, retrospective study of patients with HM3 managed with RT from November 2014 through January 2020. We analyzed baseline characteristics, RT indications, and bleeding and thrombotic complications. We found that 50 of 161 patients with HM3 (31.1%) received RT starting at a median time of 90.5 days after LVAD implantation. Patients on RT were older and more likely to have ischemic heart failure than patients on standard anti-thrombotic therapy (ST). The most common indication for RT was gastrointestinal bleeding (29 patients [58.0%]). At 1-year follow-up, 5.0% of patients on RT developed a thrombotic event. Switching patients from ST to RT reduced the occurrence of major bleeding from 1.252 to 0.324 events per patient-year (p = 0.006). In our population of patients with HM3 LVAD, RT reduces bleeding without increasing the incidence of thrombosis. Our retrospective study suggests that an upfront RT strategy in patients with HM3 may be beneficial and should be prospectively studied.
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http://dx.doi.org/10.1016/j.healun.2021.01.012DOI Listing
April 2021

Serial assessment of HeartMate 3 pump position and inflow angle and effects on adverse events.

Eur J Cardiothorac Surg 2021 Jun;59(6):1166-1173

Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY, USA.

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Objectives: This study analyses the position of the HeartMate 3 left ventricular assist device on serial radiographs to assess positional change and possible correlation with adverse events.

Methods: We retrospectively analysed 59 left ventricular assist device recipients who had serial chest radiographs at 1 month, 6 months and 12 months post-implantation between November 2014 and June 2018. We measured pump angle, pump-spine distance and pump-diaphragm depth and investigated their relationship to a composite outcome of heart failure readmission, low flow alarms, stroke or inflow/outflow occlusion requiring surgical repositioning through recurrent event survival modelling.

Results: Between 1 and 6 months, the absolute pump-spine distance changed by 10.00 mm (P < 0.01) and the absolute pump-diaphragm depth changed by 18.80 mm (P < 0.01). These parameters did not change significantly between 6 and 12 months post-implantation. Pump angle did not change significantly over any period. Twenty-six patients experienced the composite outcome; in these patients, the median 1-month pump angle was 66.2° (interquartile range 54.5-78.0) as compared to 59.0° (interquartile range 47.0-65.0) in the 33 patients who did not have adverse events (P = 0.04). Pump depth and pump-spine distance at 1 month were not associated with the composite outcome. Change in pump depth between 1 and 6 months [hazard ratio (HR) 1.019; 95% confidence interval (CI) 1.000-1.039] and between 6 and 12 months (HR 1.020; 95% CI 1.000-1.040) were weakly associated with the composite outcome.

Conclusions: Larger pump angles are associated with the composite outcome of position-related adverse events. Pump depth movement is weakly associated with the composite outcome.
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http://dx.doi.org/10.1093/ejcts/ezaa475DOI Listing
June 2021

Influence of Atrial Fibrillation on Functional Tricuspid Regurgitation in Patients With HeartMate 3.

J Am Heart Assoc 2021 Feb 8;10(3):e018334. Epub 2021 Jan 8.

Division of Cardiothoracic Surgery Department of Surgery Columbia University Medical Center New York NY.

Background Functional tricuspid regurgitation (TR) can occur secondary to atrial fibrillation (AF). The impact of AF on functional TR and cardiovascular events is uncertain in patients with left ventricular assist devices. This study aimed to investigate the effect of AF on functional TR and cardiovascular events in patients with a HeartMate 3 left ventricular assist device. Methods and Results We retrospectively reviewed 133 patients who underwent HeartMate 3 implantation at our center between November 2014 and November 2018. We excluded patients who had undergone previous or concomitant tricuspid valve procedures and those whose echocardiographic images were of insufficient quality. The primary end point was death and the presence of a cardiovascular event at 1 year. We defined cardiovascular event as a composite of death, stroke, and hospital readmission due to recurrent heart failure and significant residual TR as vena contracta width ≥3 mm. In total, 110 patients were included in this analysis. Patients were divided into 3 groups: no AF (n=51), paroxysmal AF (n=40), and persistent AF (PeAF) (n=19). Kaplan-Meier analysis showed that patients with PeAF had the worst survival (no AF 98%, paroxysmal AF 98%, PeAF 84%, log-rank =0.038) and event-free rate (no AF 93%, paroxysmal AF 89%, PeAF 72%, log-rank =0.048) at 1 year. Thirty-one (28%) patients had residual TR 1 month after left ventricular assist device implantation. Patients with residual TR had a significantly poor prognosis compared with those without residual TR (log-rank =0.014). Conclusions PeAF was associated with increased mortality, cardiovascular events, and residual TR compared with no AF and paroxysmal AF.
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http://dx.doi.org/10.1161/JAHA.120.018334DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955423PMC
February 2021

Consequences of functional mitral regurgitation and atrial fibrillation in patients with left ventricular assist devices.

J Heart Lung Transplant 2020 12 3;39(12):1398-1407. Epub 2020 Sep 3.

Division of Cardiothoracic Surgery. Electronic address:

Background: Functional mitral regurgitation (MR) (FMR) and atrial fibrillation (AF) are common in patients undergoing left ventricular assist device (LVAD) implantation. However, the impact of FMR and AF on clinical outcomes is uncertain. This study aimed to investigate the characteristics and prognostic significance of FMR and AF in patients with LVADs.

Methods: We retrospectively reviewed all patients who underwent LVAD implantation at our center between January 2010 and December 2017. We defined significant FMR as the ratio of MR color jet area to left atrial area of >20% and persistent or permanent AF (PeAF) as persistent or permanent AF at LVAD implantation.

Results: A total of 380 patients were included in this analysis. Patients were divided into 6 groups: patients with no PeAF and no significant FMR (Group 1), patients with no PeAF but with significant FMR (Group 2), patients with PeAF but no significant FMR (Group 3), patients with PeAF and significant FMR (Group 4), patients with concomitant mitral valve surgery (MVS) at LVAD implantation and without PeAF (Group 5), and patients with concomitant MVS and with PeAF (Group 6). A total of 56 patients (15%) died within 2 years. Kaplan-Meier curve analysis demonstrated a 2-year survival of 81% in Group 1, 89% in Group 2, 87% in Group 3, 47% in Group 4, 87% in Group 5, and 79 % in Group 6 (log-rank test, p < 0.001). The multivariable Cox proportional-hazards model showed that classification in Group 4 was an independent predictor of mortality (hazard ratio, 4.31; 95% CI: 2.19-8.46; p < 0.001).

Conclusions: The coexistence of significant FMR and PeAF may represent a poor prognostic marker in patients undergoing LVAD implantation.
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http://dx.doi.org/10.1016/j.healun.2020.08.020DOI Listing
December 2020

United network for organ sharing outcomes after heart transplantation for al compared to ATTR cardiac amyloidosis.

Clin Transplant 2020 10 24;34(10):e14028. Epub 2020 Jul 24.

Center for Advanced Cardiac Care, Division of Cardiology, Columbia College of Physicians & Surgeons, New York, NY, USA.

Light-chain (AL) cardiac amyloidosis (CA) has a worse prognosis than transthyretin (ATTR) CA. In this single-center study, we compared post-heart transplant (OHT, orthotopic heart transplantation) survival for AL and ATTR amyloidosis, hypothesizing that these differences would persist post-OHT. Thirty-nine patients with CA (AL, n = 18; ATTR, n = 21) and 1023 non-amyloidosis subjects undergoing OHT were included. Cox proportional hazards modeling was used to evaluate the impact of amyloid subtype and era (early era: from 2001 to 2007; late era: from 2008 to 2018) on survival post-OHT. Survival for non-amyloid patients was greater than ATTR (P = .034) and AL (P < .001) patients in the early era. One, 3-, and 5-year survival rates were higher for ATTR patients than AL patients in the early era (100% vs 75%, 67% vs 50%, and 67% vs 33%, respectively, for ATTR and AL patients). Survival in the non-amyloid cohort was 87% at 1 year, 81% at 3 years, and 76% at 5 years post-OHT. In the late era, AL and ATTR patients had unadjusted 1-year, 3-year, and 5-year survival rates of 100%, which was comparable to non-amyloid patients (90% vs 84% vs 81%). Overall, these findings demonstrate that in the current era, differences in post-OHT survival for AL compared to ATTR are diminishing; OHT outcomes for selected patients with CA do not differ from non-amyloidosis patients.
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http://dx.doi.org/10.1111/ctr.14028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7744118PMC
October 2020

Left Atrial Appendage Occlusion With Left Ventricular Assist Device Decreases Thromboembolic Events.

Ann Thorac Surg 2019 04 23;107(4):1181-1186. Epub 2018 Oct 23.

Department of Medicine, University of Chicago, Chicago, Illinois; Section of Cardiology, University of Chicago, Chicago, Illinois. Electronic address:

Background: Thromboembolic events (TEs) are common adverse events with continuous-flow left ventricular assist devices (LVADs). Left atrial appendage occlusion (LAAO) is commonly performed at the time of a cardiac operation. The effect of LAAO on TEs in LVAD patients remains unknown.

Methods: All patients receiving a first LVAD implantation between January 2013 and January 2014 were reviewed. TEs included device thrombosis and ischemic cerebrovascular accidents. The incidence of TEs with respect to LAAO was evaluated using Kaplan-Meier and Cox proportional hazards analyses.

Results: The analysis included 102 patients, 36 of whom received LAAO and 66 did not. LAAO patients were an average age of 60 years, and 69.4% were men. Non-LAAO patients were an average age of 59.3 years, and 71.2% were men. There were no significant differences in characteristics other than history of coronary artery bypass grafting (8.3% of LAAO vs 44% of non-LAAO, p = 0.0005). Preoperative atrial fibrillation was present in 19 LAAO patients (52.7%) and in 36 non-LAAO patients (54.5%; p = 1.0). Patients were monitored for a median of 306 days. TEs occurred in 3 LAAO patients (1 device thrombosis and 2 cerebrovascular accidents) compared with 15 non-LAAO patients (5 device thromboses and 11 cerebrovascular accidents, p = 0.049). In a Cox hazards analysis including age, sex, hypertension, and atrial fibrillation, LAAO demonstrated a decreased risk of TE (hazard ratio, 0.27; 95% confidence interval, 0.08 to 0.95; p = 0.04).

Conclusions: In patients undergoing LVAD implantation, LAAO is associated with reduced TEs, and this effect may be independent of atrial fibrillation. A prospective randomized study to examine the efficacy LAAO in prevention of TE is needed to confirm these findings.
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http://dx.doi.org/10.1016/j.athoracsur.2018.09.004DOI Listing
April 2019

Predictors of survival following trans-catheter aortic valve closure for left ventricular assist device associated aortic insufficiency.

Catheter Cardiovasc Interv 2016 Apr 3;87(5):971-9. Epub 2015 Nov 3.

Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, Illinois.

Objective: This study sought to assess the long-term clinical benefits and predictors of survival of trans-catheter aortic valve closure in left ventricular assist device (LVAD) patients.

Background: LVADs have been shown to increase survival and quality of life in patients with end-stage heart failure. However, severe aortic insufficiency (AI) can develop in up to 50% of patients at 12 months resulting in significant morbidity and mortality. Trans-catheter treatment of LVAD associated AI has emerged as a potential alternative to surgical treatment.

Methods: We conducted a retrospective analysis of all patients undergoing trans-catheter aortic valve closure using an Amplatzer Multi-Fenestrated Septal Occluder "Cribriform" device to assess potential clinical and procedural factors associated with survival. Student's t-tests were used to compare baseline patient demographics and procedural characteristics, as well as patient outcomes immediately post procedure and at 6 months. A P-value of less than 0.05 was considered statistically significant.

Results: A total of 10 patients (70% male, median age 59 years) were included. Technical success was accomplished in 100% of patients with a 6 month survival rate of 30% (3/10). Compared with survivors, non-survivors had a higher rate of pre-procedural clinical co-morbidities, an increased likelihood of right ventricular failure, and received larger occluder devices.

Conclusions: Trans-catheter aortic valve closure successfully treats late severe AI in LVAD patients, however, the presence or development of right heart failure portends a worse prognosis. Further studies are needed to investigate the factors involved in the development of right ventricular failure, and potential treatment, in patients undergoing trans-catheter aortic valve closure.
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http://dx.doi.org/10.1002/ccd.26280DOI Listing
April 2016

Left Ventricular Decompression During Speed Optimization Ramps in Patients Supported by Continuous-Flow Left Ventricular Assist Devices: Device-Specific Performance Characteristics and Impact on Diagnostic Algorithms.

J Card Fail 2015 Oct 25;21(10):785-91. Epub 2015 Jun 25.

Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York.

Background: Echocardiographic ramp tests have been widely used to help guide speed adjustments and for identification of potential device malfunctions in patients with axial continuous-flow left ventricular assist devices (LVADs) (Heartmate II LVAD [HMII]). Recently, the use of centrifugal-flow LVADs (Heartware LVAD [HVAD]) has been on the rise. The purpose of this study was to evaluate the utility of ramp tests for assessing ventricular decompression in HVAD patients.

Methods And Results: In this prospective study, ramp tests were performed before index hospitalization discharge or at the time of device malfunction. Vital signs, device parameters (including flow), and echocardiographic parameters (including left ventricular end-diastolic dimension [LVEDD], frequency of aortic valve [AV] opening, and valvular insufficiency) were recorded in increments of 100 rpm, from 2,300 rpm to 3,200 rpm. Twenty-six ramp tests were performed, 19 for speed optimization and 7 for device malfunction assessment. The average speed after the speed optimization ramp tests was 2,534.74 ± 156.32 RPM, and the AV closed at a mean speed of 2,751.77 ± 227.16 rpm, with 1 patient's valve remaining open at the maximum speed. The reduction in LVEDD for each speed increase was significantly different when the AV was open or closed, at -0.09 cm/increment and -0.15 cm/increment, respectively (P = .013), which is significantly different than previously established HMII LVEDD slopes. There were also significant changes in overall device flow (P = .001), upper flow (P = .031), and lower flow (P = .003) after AV closure. The power slope did not change significantly after the AV closed (P = .656). Five of the 19 tests were stopped before completion owing to suction events, but all tests reached ≥3,000 rpm.

Conclusions: The parameter slopes for the HMII cannot be directly applied to ramp studies in HVAD patients. Overall, the LVEDD slope is drastically smaller in magnitude than the previously reported HMII findings, and speed adjustments were not based on the degree of left ventricular unloading. Therefore, the slope of the LVEDD-rpm relationship is not likely to be helpful in evaluating HVAD function.
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http://dx.doi.org/10.1016/j.cardfail.2015.06.010DOI Listing
October 2015

Successful percutaneous trans-catheter treatment of left ventricular assist device outflow graft stenosis with a covered stent.

ESC Heart Fail 2015 Jun 30;2(2):100-102. Epub 2015 Apr 30.

Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, IL, USA.

Left ventricular assist devices improve survival in patients with advanced heart failure but can be associated with significant complication including infection, pump thrombosis, and de novo severe aortic insufficiency. Outflow graft stenosis is a much more rare complication, but one with significant hemodynamic consequences. Surgical repair is often necessary, but many patients are too high risk for further surgical intervention. We describe the first case of left ventricular assist device outflow graft stenosis treated with percutaneous trans-catheter placement of a covered stent.
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http://dx.doi.org/10.1002/ehf2.12030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5513496PMC
June 2015

Advances in the pathophysiology and treatment of heart failure with preserved ejection fraction.

Curr Opin Cardiol 2015 May;30(3):250-8

Section of Cardiology, University of Chicago, Chicago, Illinois, USA.

Purpose Of Review: With the failure of multiple trials to identify a successful therapy for heart failure with preserved ejection fraction (HFpEF), attention has shifted to defining specific phenotypes within the HFpEF spectrum in an effort to develop a targeted approach to treatment. Here we summarize the most recent studies investigating the pathophysiology and clinical features of HFpEF, and discuss recent clinical trials in the context of developing treatments that look toward the underlying cause of this disorder.

Recent Findings: Advances in basic science and clinical research have further characterized HFpEF, identifying multiple pathophysiological mechanisms that ultimately lead to exercise intolerance and volume overload. The success of small studies focused on specific subsets of the HFpEF population has promoted the concept that there may not be one treatment strategy that can universally be applied to HFpEF.

Summary: HFpEF is associated with significant morbidity and mortality and accounts for approximately half of patients with chronic heart failure. HFpEF is a complex disease, encompassing a diverse cohort of patients and marked by the presence of multiple etiological mechanisms. The failure to develop successful therapies for the management of HFpEF may be because of inadequate standardization of the HFpEF diagnosis, overly broad inclusion criteria and inadequate differentiation of disease subtypes. Given the heterogeneity among patients with HFpEF, much of the current research is focused on understanding of pathophysiology and identifying disease phenotypes that may respond to a targeted treatment approach. Several newer approaches, including neprilysin inhibition and device therapy, offer promise for a new era of HFpEF treatment.
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http://dx.doi.org/10.1097/HCO.0000000000000163DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5391977PMC
May 2015

Heart rescue: the role of mechanical circulatory support in the management of severe refractory cardiogenic shock.

Curr Opin Crit Care 2012 Oct;18(5):409-16

Advanced Heart Failure Service, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.

Purpose Of Review: Cardiogenic shock is present in 3.5% of patients presenting with acute decompensated heart failure. Despite advances in therapy, mortality remains high, approaching 70% in some settings. Recent management strategies have incorporated the use of mechanical circulatory support (MCS), which has been associated with better survival in nonrandomized trials. MCS is increasingly used in the acute setting and has become an important treatment modality for cardiogenic shock.

Recent Findings: Small studies have demonstrated improved survival when MCS is instituted early in the management of cardiogenic shock. Numerous case reports support the benefit of MCS for various causes of cardiogenic shock, including acute myocardial infarction, cardiac allograft rejection, myocarditis and refractory arrhythmias.

Summary: This article will review novel strategies in the management of cardiogenic shock including percutaneous MCS (intra-aortic balloon pump, Impella, TandemHeart, venoarterial extracorporeal membrane oxygenation) and surgically implanted devices (CentriMag) that are used for short-term management. We will review the mechanisms involved in cardiogenic shock and discuss management and device selection strategies.
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http://dx.doi.org/10.1097/MCC.0b013e328357f1e6DOI Listing
October 2012

Right ventricular performance in chronic congestive heart failure.

Cardiol Clin 2012 May;30(2):271-82

Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, GRB-800, Boston, MA 02114, USA.

Right ventricular physiology is characterized by its close relationship with the pulmonary circuit. The right ventricle can accommodate significant changes in preload, but is highly sensitive to increases in afterload. Progressive dilatation and dysfunction can initiate a cycle of oxygen supply-demand mismatch that ultimately leads to right ventricular failure. Echocardiography and cardiac magnetic resonance imaging are the primary modalities used for non-invasive assessment of right ventricular function. The management of right ventricular failure centers on the optimization of preload, afterload and contractility. Few targeted therapies exist, although novel agents have shown promise in early studies.
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http://dx.doi.org/10.1016/j.ccl.2012.03.011DOI Listing
May 2012