Publications by authors named "Keyur B Shah"

94 Publications

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

Phenotypic Spectrum of Transthyretin Cardiac Amyloidosis in a Family: Impact of Mutation Zygosity and Sex.

JACC CardioOncol 2021 Oct 19;3(4):602-605. Epub 2021 Oct 19.

Division of Cardiology, Virginia Commonwealth University Health, Pauley Heart Center, Richmond, Virginia, USA.

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http://dx.doi.org/10.1016/j.jaccao.2021.07.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8543089PMC
October 2021

A bridge-to-bridge approach to heart transplantation using extracorporeal membrane oxygenation and total artificial heart.

J Thorac Cardiovasc Surg 2021 Sep 20. Epub 2021 Sep 20.

Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Quebec, Canada.

Background: This study aims to describe the outcomes after heart transplantation using a bridge-to-bridge strategy with a sequence of extracorporeal membrane oxygenation (ECMO) support followed by temporary total artificial heart implantation (TAH-t).

Methods: A retrospective, multicenter analysis of 54 patients who underwent TAH-t implantation following an ECMO for cardiogenic shock was performed (ECMO-TAH-t group). A control group of 163 patients who underwent TAH-t implantation as a direct bridge to transplantation (TAH-t group) was used to assess this strategy's impact on outcomes.

Results: Fifty-four patients, averaging 47 ± 13 year old, underwent implantation of a TAH-t after 5.3 ± 3.4 days of ECMO perfusion for cardiogenic shock. In the ECMO-TAH-t group, 20 patients (20/54%; 37%) died after TAH-t implantation and 57 patients (57/163%; 35%) died in the TAH-t group (Gray test; P = .49). The top 3 causes of death of patients on TAH-t support were multisystem organ failure (40%), sepsis (20%), and neurologic events (20%). Overall, 32 patients (32/54%; 59%) underwent heart transplantation in the ECMO-TAH-t group compared with 106 patients (106/163%, 65%) in the TAH-t group (P = .44). No significant difference in survival was observed at 6 months, 1 year, and 3 years after heart transplant (ECMO-TAH-t group: 94%, 87%, and 80% vs 87%, 83%, and 76% in the TAH-t group, respectively). Deterioration of liver function (bilirubin, aspartate transaminase, and alanine aminotransferase levels on TAH-t) was associated with increased mortality before heart transplant in both groups.

Conclusions: Sequential bridging from ECMO to TAH-t followed by heart transplantation is a viable option for a group of highly selected patients.
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http://dx.doi.org/10.1016/j.jtcvs.2021.09.015DOI Listing
September 2021

Disease-Modifying Treatments for Transthyretin Amyloidosis.

J Cardiovasc Pharmacol 2021 11;78(5):e641-e647

The Pauley Heart Center, Virginia Commonwealth University, Richmond, VA; and.

Abstract: The transthyretin (TTR) amyloidoses result from misfolding of the protein leading to fibril formation and aggregation as amyloid deposits in predominantly the cardiovascular and nervous systems. Cardiac involvement can manifest as heart failure, arrhythmias, and valvular disease. Neurologic involvement can cause sensorimotor polyneuropathies, mononeuropathies, and dysautonomia. Previously, treatment has focused on management of these symptoms and disease sequelae, with a high rate of mortality due to the absence of disease-modifying therapies. In this article, we review novel treatments focusing on 3 mechanistic pathways: (1) silencing of the TTR gene to suppress production, (2) stabilizing of TTR tetramers to prevent misfolding, or (3) disrupting of existing TTR amyloid fibrils to promote reabsorption.
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http://dx.doi.org/10.1097/FJC.0000000000001115DOI Listing
November 2021

Caregiver Health-Related Quality of Life, Burden, and Patient Outcomes in Ambulatory Advanced Heart Failure: A Report From REVIVAL.

J Am Heart Assoc 2021 07 10;10(14):e019901. Epub 2021 Jul 10.

Feinberg School of Medicine Northwestern University Chicago IL.

Background Heart failure (HF) imposes significant burden on patients and caregivers. Longitudinal data on caregiver health-related quality of life (HRQOL) and burden in ambulatory advanced HF are limited. Methods and Results Ambulatory patients with advanced HF (n=400) and their participating caregivers (n=95) enrolled in REVIVAL (Registry Evaluation of Vital Information for VADs [Ventricular Assist Devices] in Ambulatory Life) were followed up for 24 months, or until patient death, left ventricular assist device implantation, heart transplantation, or loss to follow-up. Caregiver HRQOL (EuroQol Visual Analog Scale) and burden (Oberst Caregiving Burden Scale) did not change significantly from baseline to follow-up. At time of caregiver enrollment, better patient HRQOL by Kansas City Cardiomyopathy Questionnaire was associated with better caregiver HRQOL (=0.007) and less burden by both time spent (<0.0001) and difficulty (=0.0007) of caregiving tasks. On longitudinal analyses adjusted for baseline values, better patient HRQOL (=0.034) and being a married caregiver (=0.016) were independently associated with better caregiver HRQOL. Patients with participating caregivers (versus without) were more likely to prefer left ventricular assist device therapy over time (odds ratio, 1.43; 95% CI, 1.03-1.99; =0.034). Among patients with participating caregivers, those with nonmarried (versus married) caregivers were at higher composite risk of HF hospitalization, death, heart transplantation or left ventricular assist device implantation (hazard ratio, 2.99; 95% CI, 1.29-6.96; =0.011). Conclusions Patient and caregiver characteristics may impact their HRQOL and other health outcomes over time. Understanding the patient-caregiver relationship may better inform medical decision making and outcomes in ambulatory advanced HF.
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http://dx.doi.org/10.1161/JAHA.120.019901DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8483456PMC
July 2021

Combined Heart-Liver and Domino Liver Transplantation in Familial Amyloidosis.

Am Surg 2021 Jun 1:31348211023427. Epub 2021 Jun 1.

Department of Surgery, Hume-Lee Transplant Center, 6887Virginia Commonwealth University, Richmond, VA, USA.

Background: Combined heart-liver transplantation (CHLT) is the only curative option for patients with concomitant pathology affecting the heart and liver. In some cases, the native livers of familial amyloidosis (FA) patients may be suitable for domino transplantation into other recipients.

Methods: Retrospective analysis (2013 to 2019) of all CHLT at our center was performed. Continuous data were presented as mean with standard deviation and discrete variables as percentages.

Results: Familial amyloidosis was the indication for CHLT in 5 out of 6 patients. The mean recipient age was 55 ± 5.62 years. Two patients were bridged with total artificial heart. The mean model for end-stage liver disease score at transplant was 17.17 ± 3.7. Two explanted livers were used for transplantation in a domino fashion. The median intensive care and hospital stays were 5.5 and 19 days, respectively. Complications included renal failure (1), groin abscess (1), pulmonary embolism (1), and cardiac rejection (1). Patient and graft survival for both organs was 100% at a median follow-up of 59 (range 20-76) months.

Discussion: Combined heart-liver transplantation for FA achieves excellent outcomes. The possible use of livers explanted from patients with FA for domino liver transplantation can contribute to the liver donor pool.
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http://dx.doi.org/10.1177/00031348211023427DOI Listing
June 2021

False-Positive Technetium-Pyrophosphate Scintigraphy in Two Patients With Hypertrophic Cardiomyopathy.

Circ Heart Fail 2021 03 5;14(3):e007558. Epub 2021 Mar 5.

Division of Cardiology within Pauley Heart Center (Z.T., C.R.T., K.R., K.B.S.), Virginia Commonwealth University Health System, Richmond, VA.

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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.120.007558DOI Listing
March 2021

An interventional approach to left ventricular assist device outflow graft obstruction.

Catheter Cardiovasc Interv 2021 11 15;98(5):969-974. Epub 2021 Feb 15.

Division of Cardiology, VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA.

Background: LVADs provide life-sustaining treatment for patients with heart failure, but their complexity allows for complications. One complication, LVAD outflow graft obstruction, may be misdiagnosed as intraluminal thrombus, when more often it is extraluminal compression from biodebris accumulation. It can often be treated endovascularly with stenting. This case series describes diagnostic and procedural techniques for the treatment of left ventricular assist device (LVAD) outflow graft obstruction.

Methods: We present four patients with LVADs who developed LVAD outflow graft obstruction within the bend relief-covered segment. All were initially diagnosed with computed tomographic angiography (CTA). All underwent invasive evaluation with intravascular ultrasound (IVUS), then were treated with stenting. After misdiagnosing a twist, we developed the technique of balloon "graftoplasty" to ensure suitability for stent delivery in subsequent cases.

Results: All patients presented with low-flow alarms and symptoms of low output, and were diagnosed with outflow graft obstruction by CTA. In all four, IVUS confirmed an extraluminal etiology. Patient 1 was treated with stenting and had a good outcome. Patient 2's obstruction was from twisting, rather than biodebris accumulation, and had sub-optimal stent expansion and ultimately required surgery. Balloon "graftoplasty" was used in subsequent cases to ensure subsequent stent expansion. Patients 3 and 4 were successfully stented. All improved after treatment.

Conclusions: In patients with LVAD outflow graft obstruction, IVUS can distinguish intraluminal thrombus from extraluminal compression. Balloon "graftoplasty" can ensure that the outflow graft will respond to stenting. Many cases of LVAD outflow graft obstruction should be amenable to endovascular treatment.
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http://dx.doi.org/10.1002/ccd.29556DOI Listing
November 2021

Predictive Value of Cardiopulmonary Exercise Testing Parameters in Ambulatory Advanced Heart Failure.

JACC Heart Fail 2021 03 3;9(3):226-236. Epub 2021 Feb 3.

Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA. Electronic address:

Objectives: This study sought to determine cardiopulmonary exercise (CPX) predictors of the combined outcome of durable mechanical circulatory support (MCS), transplantation, or death at 1 year among patients with ambulatory advanced heart failure (HF).

Background: Optimal CPX predictors of outcomes in contemporary ambulatory advanced HF patients are unclear.

Methods: REVIVAL (Registry Evaluation of Vital Information for ventricular assist devices [VADs] in Ambulatory Life) enrolled 400 systolic HF patients, INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) profiles 4-7. CPX was performed by 273 subjects 2 ± 1 months after study enrollment. Discriminative power of maximal (peak oxygen consumption [peak VO]; VO pulse, circulatory power [CP]; peak systolic blood pressure • peak VO], peak end-tidal pressure CO [PEtCO], and peak Borg scale score) and submaximal CPX parameters (ventilatory efficiency [VE/VCO slope]; VO at anaerobic threshold [VOAT]; and oxygen uptake efficiency slope [OUES]) to predict the composite outcome were assessed by univariate and multivariate Cox regression and Harrell's concordance statistic.

Results: At 1 year, there were 39 events (6 transplants, 15 deaths, 18 MCS implantations). Peak VO, VOAT, OUES, peak PEtCO, and CP were higher in the no-event group (all p < 0.001), whereas VE/VCO slope was lower (p < 0.0001); respiratory exchange ratio was not different. CP (hazard ratio [HR]: 0.89; p = 0.001), VE/VCO slope (HR: 1.05; p = 0.001), and peak Borg scale score (HR: 1.20; p = 0.005) were significant predictors on multivariate analysis (model C-statistic: 0.80).

Conclusions: Among patients with ambulatory advanced HF, the strongest maximal and submaximal CPX predictor of MCS implantation, transplantation, or death at 1 year were CP and VE/VCO respectively. The patient-reported measure of exercise effort (Borg scale score) contributed substantially to the prediction of outcomes, a surprising and novel finding that warrants further investigation. (Registry Evaluation of Vital Information for VADs in Ambulatory Life [REVIVAL]; NCT01369407).
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http://dx.doi.org/10.1016/j.jchf.2020.11.008DOI Listing
March 2021

Outcomes after heart transplantation and total artificial heart implantation: A multicenter study.

J Heart Lung Transplant 2021 03 28;40(3):220-228. Epub 2020 Nov 28.

Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.

Background: We sought to assess the outcomes after heart transplantation (HT) of patients supported with a temporary total artificial heart (t-TAH) as a bridge to transplantation in high-volume centers.

Methods: A retrospective analysis of 217 consecutive patients who underwent t-TAH (SynCardia Systems, Tucson, Arizona) implantation between January 2014 and May 2019 in 6 high-volume North American centers was performed. End points included survival and adverse events after t-TAH and HT.

Results: The mean age of patients was 49 ± 12 years, and heart failure etiologies were non-ischemic dilated cardiomyopathy (36%), ischemic (25%), restrictive (12%), and cardiac graft failure (9%). A total of 101 (48%) patients had Interagency Registry for Mechanically Assisted Circulatory Support patient profile 1, and 65 (31%) had Interagency Registry for Mechanically Assisted Circulatory Support patient profile 2. At the end of the study period, 138 of 217 (63.5%) patients had undergone HT, and 75 (34.5%) patients died before HT. The mean time between t-TAH implantation and HT averaged 181 ± 179 days (range: 0-849) and the mean follow-up after HT was 35 ± 25 months. The overall survival in the entire cohort was 75%, 64%, and 58% at 1, 2, and 5 years, respectively. Post-transplant survival was 88%, 84%, 79%, and 74% at 6 months, 1 year, 2 years, and 5 years, respectively. Among the 32 patients (23%) who died after HT, the main causes of death were chronic allograft vasculopathy (25%), multiorgan failure (21.8%), sepsis (15.6%), and stroke (9%).

Conclusion: In this multicenter study, almost two thirds of patients implanted with a t-TAH could be transplanted. The overall and post-transplantation survival after t-TAH was satisfactory in these critically ill patients.
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http://dx.doi.org/10.1016/j.healun.2020.11.012DOI Listing
March 2021

Transcatheter Heart Valve Thrombosis in a Patient With a Left Ventricular Assist Device.

Circ Heart Fail 2020 09 26;13(9):e007112. Epub 2020 Aug 26.

Division of Cardiology (K.G.R., M.C.S., K.B.S., H.L.B., Z.M.G.), Pauley Heart Center, Virginia Commonwealth University, Richmond.

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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.120.007112DOI Listing
September 2020

Elevated AT1R Antibody and Morbidity in Patients Bridged to Heart Transplant Using Continuous Flow Left Ventricular Assist Devices.

J Card Fail 2020 Nov 24;26(11):959-967. Epub 2020 Jun 24.

Division of Cardiology, Department of Internal Medicine and Pauley Heart Center, Virginia Commonwealth University Health Systems, Richmond, Virginia. Electronic address:

Background: We studied longitudinal levels of angiotensin-II type 1 receptor antibody (AT1R-Ab) and their effects on adverse events (death, treated rejection and cardiac allograft vasculopathy) in patients who were bridged to heart transplant using a continuous flow left ventricular assist device (LVAD).

Methods And Results: Sera of 77 patients bridged to heart transplant (from 2009 to 2017) were tested for AT1R-Ab and CRP before and after LVAD. Elevated AT1R-Ab was defined as >10.0 U/mL. The median follow-up after transplant was 3.6 years (interquartile range, 2.2-5.6 years). After LVAD, AT1R-Ab levels increased from baseline and remained elevated until transplant. Freedom from adverse events at 5 years was lower in those with elevated AT1R-Ab levels at time of transplant. In an adjusted, multivariable Cox analysis, an AT1R-Ab level of >10 U/mL was associated with developing the primary end point (adjusted hazard ratio 3.4, 95% confidence interval 1.2-9.2, P = .017). Although C-reactive protein levels were high before and after LVAD placement, C-reactive protein did not correlate with AT1R-Ab.

Conclusions: In LVAD patients bridged to heart transplant, an increased AT1R-Ab level at time of transplant was associated with poor outcomes after heart transplant. Post-LVAD AT1R-Ab elevations were not correlated with serum markers of systemic inflammation. Larger studies are needed to examine the pathologic role of AT1R-Ab in heart transplant.
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http://dx.doi.org/10.1016/j.cardfail.2020.06.010DOI Listing
November 2020

Predictors of Renal Failure in Patients Treated With the Total Artificial Heart.

J Card Fail 2020 Jul 26;26(7):588-593. Epub 2020 May 26.

The Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia. Electronic address:

Background: The incidence of hemodialysis (HD)-dependent renal failure after total artificial heart (TAH) implantation is high. We sought to determine the preoperative predictors of HD after TAH implantation.

Methods And Results: We studied 87 patients after TAH implantation at our institution between April 2006 and March 2017. Baseline clinical data were obtained from the medical records, and patients were followed until death or heart transplantation. We performed logistic regression analysis to identify predictors of HD after TAH implantation. Of the patients, 24 (28%) required postimplantation HD. Those requiring HD were more likely to have histories of coronary artery disease (58% vs 29%; P = 0.01), required preoperative membrane oxygenation (33% vs 4.8%; P = 0.001) and had lower baseline estimated glomerular filtration rates (54 ± 29 vs 67 ± 24 mL/min/1.73m; P = 0.04). Patients requiring HD were at a higher risk of death on device at 1 year (33% vs 5%, P = 0.001; log rank test: P =0.001, hazard ratio 6.6 [95% CI:1.8-23], P = 0.003).

Conclusions: The incidence of postimplantation HD is high and is associated with increased likelihood of mortality. Lower baseline estimated glomerular filtration rates, histories of coronary artery disease and preoperative membrane oxygenation support are predictors of postimplantation requirement of HD. These data may help to identify patients at risk for adverse outcomes after TAH implantation.
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http://dx.doi.org/10.1016/j.cardfail.2020.05.011DOI Listing
July 2020

The effects of canagliflozin compared to sitagliptin on cardiorespiratory fitness in type 2 diabetes mellitus and heart failure with reduced ejection fraction: The CANA-HF study.

Diabetes Metab Res Rev 2020 11 15;36(8):e3335. Epub 2020 Jun 15.

Division of Cardiology, Department of Internal Medicine, VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA.

Background: Canagliflozin reduces hospitalizations for heart failure (HF) in type 2 diabetes mellitus (T2DM). Its effect on cardiorespiratory fitness and cardiac function in patients with established HF with reduced ejection fraction (HFrEF) is unknown.

Methods: We conducted a double-blind randomized controlled trial of canagliflozin 100 mg or sitagliptin 100 mg daily for 12 weeks in 88 patients, and measured peak oxygen consumption (VO ) and minute ventilation/carbon dioxide production (VE/VCO ) slope (co-primary endpoints for repeated measure ANOVA time_x_group interaction), lean peak VO , ventilatory anaerobic threshold (VAT), cardiac function and quality of life (ie, Minnesota Living with Heart Failure Questionnaire [MLHFQ]), at baseline and 12-week follow-up.

Results: The study was terminated early due to the new guidelines recommending canagliflozin over sitagliptin in HF: 17 patients were assigned to canagliflozin and 19 to sitagliptin, total of 36 patients. There were no significant changes in peak VO and VE/VCO slope between the two groups (P = .083 and P = .98, respectively). Canagliflozin improved lean peak VO (+2.4 mL kg min , P = .036), VAT (+1.5 mL kg min , P = .012) and VO matched for respiratory exchange ratio (+2.4 mL Kg min , P = .002) compared to sitagliptin. Canagliflozin also reduced MLHFQ score (-12.1, P = .018).

Conclusions: In this small and short-term study of patients with T2DM and HFrEF, interrupted early after only 36 patients, canagliflozin did not improve the primary endpoints of peak VO or VE/VCO slope compared to sitagliptin, while showing favourable trends observed on several additional surrogate endpoints such as lean peak VO , VAT and quality of life.
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http://dx.doi.org/10.1002/dmrr.3335DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7685099PMC
November 2020

Hospitalizations and Outcomes in Patients Implanted with the Total Artificial Heart and Discharged with a Portable Driver.

ASAIO J 2020 05;66(5):e68-e69

From The Pauley Heart Center, Divisions of Cardiovascular Medicine and Cardiothorasic Surgery, Virginia Commonwealth University Health Systems, Richmond, Virginia.

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http://dx.doi.org/10.1097/MAT.0000000000001117DOI Listing
May 2020

Neurologic Complications in Patients with Left Ventricular Assist Devices: Single Institution Retrospective Review.

World Neurosurg 2020 07 21;139:e635-e642. Epub 2020 Apr 21.

Department of Neurological Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA.

Background: Neurologic complications are common complications encountered by patients with left ventricular assist devices (LVADs). This single-center retrospective study aims to identify the incidence and risk factors of neurologic complications and interventions in patients supported with LVADs and define the associated anticoagulation management.

Methods: Between August 2009 and August 2017, 244 patients underwent LVAD implantation. Twenty-one patients were excluded for having neurologic complications before LVAD placement or for having previously undergone heart transplantation.

Results: Fifty-six patients (25%) suffered 61 complications, and 11 (19.6%) died as a result. Gender, type of LVAD, or chronic medical comorbidities evaluated did not contribute to a difference in complication rate; in contrast, length of LVAD implantation was directly related to risk of neurologic complication. Eleven patients (19.6%) underwent 13 surgical interventions including 5 mechanical thrombectomies. Anticoagulation was reversed in 16 patients and held without complication. Anticoagulation was not held for ischemic complications, and no clinically significant hemorrhagic transformation occurred. Intravenous tissue plasminogen activator was also successfully administered to 3 patients without complication.

Conclusions: Neurologic complications were observed in 25% of patients supported with LVADs, of which 20% required neurosurgical intervention. Anticoagulation can be safely withheld in patients with hemorrhagic complications. Patients with ischemic complications can continue to be anticoagulated with no significant risk of hemorrhagic transformation. Length of LVAD implantation was directly related to the risk of neurologic complication. Finally, our study adds to existing literature that mechanical thrombectomy and even intravenous tissue plasminogen activator are options for LVAD patients with ischemic complications.
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http://dx.doi.org/10.1016/j.wneu.2020.04.064DOI Listing
July 2020

Renal function after implantation of the total artificial heart.

Authors:
Keyur B Shah

Ann Cardiothorac Surg 2020 Mar;9(2):124-125

The Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA.

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http://dx.doi.org/10.21037/acs.2020.03.04DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7160630PMC
March 2020

An Emergency Medicine-focused Summary of the HFSA/SAEM/ISHLT Clinical Consensus Document on the Emergency Management of Patients With Ventricular Assist Devices.

Acad Emerg Med 2020 07 16;27(7):618-629. Epub 2020 Apr 16.

Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Mechanical circulatory support is increasingly used as a long-term treatment option for patients with end-stage heart failure. Patients with implanted ventricular assist devices are at high risk for a range of diverse medical urgencies and emergencies. Given the increasing prevalence of mechanical circulatory support devices, this expert clinical consensus document seeks to help inform emergency medicine and prehospital providers regarding the approach to acute medical and surgical conditions encountered in these complex patients.
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http://dx.doi.org/10.1111/acem.13964DOI Listing
July 2020

Impact of Socioeconomic Factors on Patient Desire for Early LVAD Therapy Prior to Inotrope Dependence.

J Card Fail 2020 Apr 4;26(4):316-323. Epub 2019 Dec 4.

Brigham and Women's Hospital, Boston, Massachusetts.

Background: Worsening heart failure (HF) and health-related quality of life (HRQOL) have been shown to impact the decision to proceed with left ventricular assist device (LVAD) implantation, but little is known about how socioeconomic factors influence expressed patient preference for LVAD.

Methods And Results: Ambulatory patients with advanced systolic HF (n=353) reviewed written information about LVAD therapy and completed a brief survey to indicate whether they would want an LVAD to treat their current level of HF. Ordinal logistic regression analyses identified clinical and demographic predictors of LVAD preference. Higher New York Heart Association (NYHA) class, worse HRQOL measured by Kansas City Cardiomyopathy Questionnaire, lower education level, and lower income were significant univariable predictors of patients wanting an LVAD. In the multivariable model, higher NYHA class (OR [odds ratio]: 1.43, CI [confidence interval]: 1.08-1.90, P = .013) and lower income level (OR: 2.10, CI: 1.18 - 3.76, P = .012 for <$40,000 vs >$80,000) remained significantly associated with wanting an LVAD.

Conclusion: Among ambulatory patients with advanced systolic HF, treatment preference for LVAD was influenced by level of income independent of HF severity. Understanding the impact of socioeconomic factors on willingness to consider LVAD therapy may help tailor counseling towards individual needs.
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http://dx.doi.org/10.1016/j.cardfail.2019.11.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141955PMC
April 2020

Determinants of Cardiorespiratory Fitness in Patients with Heart Failure Across a Wide Range of Ejection Fractions.

Am J Cardiol 2020 01 10;125(1):76-81. Epub 2019 Oct 10.

VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia. Electronic address:

Impaired cardiorespiratory fitness (CRF) in heart failure (HF) is influenced by a complex array of cardiac and extracardiac factors. The study aimed to identify clinical determinants of CRF measured as peak oxygen consumption (peak VO) in HF patients, and to determine a peak VO prediction model using regression equations. Retrospective analysis of 200 HF patients who completed treadmill cardiopulmonary exercise testing and underwent Doppler echocardiography and/or biomarker analysis on the same day was performed. After univariate linear regression analysis, a multivariate peak VO prediction model was developed using significant variables in a stepwise linear regression analysis. In subjects with repeated testing, Pearson's correlation was used to assess correlations between measured and predicted change in peak VO (Δpeak VO) over time. Mean age was 57 years, with 55% being male. Stepwise linear regression was used to generate a weighted model for peak VO: 30.895 + (-0.112•age[years]) + (0.296•hemoglobin [g/dl]) + (-0.101•E/e'[unit change]) + (-0.202• body mass index [kg/m]) + (-0.593• N-terminal pro-brain natriuretic peptide [log pg/ml])) + (-1.349•CRP [log mg/L]). Predicted peak VO correlated strongly with measured peak VO in HF with reduced ejection fraction and HF with preserved ejection fraction patients (r = +0.63, p <0.001; r = +0.64, p <0.001, respectively). Predicted Δpeak VO correlated with measured Δpeak VO (r = +0.23, p <0.001). In conclusion, in patients with HF across a wide range of left ventricular ejection fraction, age, systemic inflammation, oxygen carrying capacity, obesity, and elevated filling pressures are the strongest predictors of impaired CRF. The proposed CRF model allows prediction of peak VO in HF patients and may be used to estimate peak VO changes over time.
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http://dx.doi.org/10.1016/j.amjcard.2019.09.036DOI Listing
January 2020

HFSA/SAEM/ISHLT clinical expert consensus document on the emergency management of patients with ventricular assist devices.

J Heart Lung Transplant 2019 07;38(7):677-698

Mclaren Greater Lansing, Lansing, Michigan USA.

Mechanical circulatory support is now widely accepted as a viable long-term treatment option for patients with end-stage heart failure (HF). As the range of indications for the implantation of ventricular assist devices grows, so does the number of patients living in the community with durable support. Because of their underlying disease and comorbidities, in addition to the presence of mechanical support, these patients are at a high risk for medical urgencies and emergencies (Table 1). Thus, it is the responsibility of clinicians to understand the basics of their emergency care. This consensus document represents a collaborative effort by the Heart Failure Society of America, the Society for Academic Emergency Medicine, and the International Society for Heart and Lung Transplantation (ISHLT) to educate practicing clinicians about the emergency management of patients with ventricular assist devices. The target audience includes HF specialists and emergency medicine physicians, as well as general cardiologists and community-based providers.
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http://dx.doi.org/10.1016/j.healun.2019.05.004DOI Listing
July 2019

HFSA/SAEM/ISHLT Clinical Expert Consensus Document on the Emergency Management of Patients with Ventricular Assist Devices.

J Card Fail 2019 Jul 1;25(7):494-515. Epub 2019 Jul 1.

University of Toledo Medical Center, Toledo, Ohio, USA.

Mechanical circulatory support is now widely accepted as a viable long-term treatment option for patients with end-stage heart failure (HF). As the range of indications for the implantation of ventricular assist devices grows, so does the number of patients living in the community with durable support. Because of their underlying disease and comorbidities, in addition to the presence of mechanical support, these patients are at a high risk for medical urgencies and emergencies (Table 1). Thus, it is the responsibility of clinicians to understand the basics of their emergency care. This consensus document represents a collaborative effort by the Heart Failure Society of America, the Society for Academic Emergency Medicine, and the International Society for Heart and Lung Transplantation (ISHLT) to educate practicing clinicians about the emergency management of patients with ventricular assist devices. The target audience includes HF specialists and emergency medicine physicians, as well as general cardiologists and community-based providers.
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http://dx.doi.org/10.1016/j.cardfail.2019.01.012DOI Listing
July 2019

Educating Resident and Fellow Physicians on the Ethics of Mechanical Circulatory Support.

AMA J Ethics 2019 05 1;21(5):E407-415. Epub 2019 May 1.

An associate professor of medicine and surgery as well as the director of the Cardiovascular Critical Care, Mechanical Circulatory Support, and Cardiogenic Shock Program at the University of North Carolina at Chapel Hill.

Mechanical circulatory support (MCS) such as extracorporeal membrane oxygenation, left ventricular assist devices and total artificial hearts have altered the natural history of heart failure, and specialists in the fields of cardiology and cardiothoracic surgery are faced with more complex ethical considerations than ever before. Residency and fellowship training programs, however, do not have formal curricula in medical ethics as it applies to MCS. In response, this article proposes that ethics be integrated into graduate medical education with a focus on the following 6 constructs: patient best interest, respect for autonomy, informed consent, shared decision making, surrogate decision making, and end-of-life care. Curricula should offer learning experiences that help physicians navigate common ethical challenges encountered in practice.
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http://dx.doi.org/10.1001/amajethics.2019.407DOI Listing
May 2019

Left Ventricular Assist Device Outflow Graft Compression: Incidence, Clinical Associations and Potential Etiologies.

J Card Fail 2019 Jul 11;25(7):545-552. Epub 2019 May 11.

Division of Cardiology, VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA. Electronic address:

Background: Left ventricular assist devices (LVADs) have revolutionized the treatment of advanced heart failure, but proliferation of device therapy has unmasked potential complications. Reports have emerged of outflow graft narrowing due to extrinsic compression.

Methods And Results: The records of patients with LVADs that had been implanted at our institution were reviewed. Those who had postimplantation computed tomography angiographies sufficient to analyze the outflow graft lumen were identified, and the studies were analyzed to characterize the outflow graft lumen. We identified 241 patients; 110 (46%) had suitable computed tomography angiographies. Of those, 15 (14%) had evidence of outflow graft lumen narrowing, all in HeartMate devices and all within the portion covered by the bend relief. Of the 15, 3 underwent invasive examination, all without intraluminal thrombus but, rather, with biodebris between the bend relief and the outflow graft. Patients with HeartWare devices had a wide range of biodebris accumulation surrounding the outflow graft but no cases of lumen narrowing. On multivariable analysis, 1) time from device implant to scan, 2) nonischemic cardiomyopathy and 3) age at implant were significantly associated with higher risk of graft narrowing.

Conclusion: Outflow graft narrowing can be seen in a number of patients with HeartMate LVADs within the portion covered by the bend relief. In the limited number of patients who underwent invasive evaluation, the narrowing was found to arise from extrinsic compression rather than intraluminal thrombus. The clinical significance of this requires further investigation.
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http://dx.doi.org/10.1016/j.cardfail.2019.05.004DOI Listing
July 2019

International Society of Heart and Lung Transplantation position statement on the role of right heart catheterization in the management of heart transplant recipients.

J Heart Lung Transplant 2019 03 21;38(3):235-238. Epub 2018 Dec 21.

The Pauley Heart Center, Virginia Commonwealth University Medical Center, Richmond, Virginia.

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http://dx.doi.org/10.1016/j.healun.2018.12.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6816339PMC
March 2019

Continuous-Flow Left Ventricular Assist Device-Related Gastrointestinal Bleeding.

Cardiol Clin 2018 Nov;36(4):519-529

Advanced Heart Failure and Transplant, Pauley Heart Center, Virginia Commonwealth University, 1200 East Broad Street, PO Box: 980204, Richmond, VA 23298-0036, USA. Electronic address:

Continuous-flow (CF) left ventricular assist devices (LVADs) are a safe and durable therapeutic option for patients with advanced heart failure as a bridge to transplant or as destination therapy. Despite the remarkable technological advances in device design and increasing familiarity with the physiologic effects of CF, major complications such as gastrointestinal bleeding (GIB) continue to cause significant morbidity. The causes underlying CF-LVAD-related GIB are multifactorial. Accordingly, management strategies for CF-LVAD-related GIB encompass a wide range of therapeutic modalities. This article reviews the epidemiology, pathophysiology, risk factors, and treatment options for the management of this complex complication.
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http://dx.doi.org/10.1016/j.ccl.2018.06.006DOI Listing
November 2018

Usefulness of Estimated Plasma Volume at Postdischarge Follow-Up to Predict Recurrent Events in Patients With Heart Failure.

Am J Cardiol 2018 10 24;122(7):1191-1194. Epub 2018 Aug 24.

Division of Cardiology, Virginia Commonwealth University, Richmond, VA. Electronic address:

Hospital readmission for patients admitted with heart failure is a persistent problem. Better identification of patients at high risk of readmission for volume overload could have clinical implications. We evaluated estimated plasma volume (ePV), a marker of congestion, to predict readmission for patients seen early after discharge for heart failure. We identified patients hospitalized with a primary heart failure diagnosis and were then seen in a postdischarge clinic. We assessed clinical factors, ePV (derived from hemoglobin and hematocrit), and B-type natriuretic peptide (BNP). The primary outcome was death or readmission for heart failure within 90 days of discharge. We identified 218 patients, of whom 23% experienced the primary outcome. No clinical variables at time of admission were different between those who did and did not experience the primary outcome, nor were BNP (1,581 vs 1,267 pg/ml, p = 0.33) or ePV (6.00 vs 5.80, p = 0.36). At clinic follow-up, both BNP (1,164 vs 636, p = 0.002) and ePV (6.18 vs 5.58, p = 0.02) were higher in those with subsequent events. Kaplan-Meier survival analysis showed that the lowest tertile of ePV had significantly lower incidence of the primary outcome than the other 2 tertiles (12% vs 29% and 27%, p = 0.02). Estimated plasma volume remained independently predictive of outcomes after controlling for BNP (p <0.05). In conclusion, EPV may be predictive of death or hospital readmission in heart failure patients seen soon after discharge, independent of BNP. Its potential warrants future prospective research evaluating its utility in larger heart failure cohorts.
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http://dx.doi.org/10.1016/j.amjcard.2018.06.057DOI Listing
October 2018

Device Management and Flow Optimization on Left Ventricular Assist Device Support.

Crit Care Clin 2018 Jul;34(3):453-463

Division of Cardiology, Department of Internal Medicine, Advanced Heart Failure and Transplantation, The Pauley Heart Center, Virginia Commonwealth University, 1200 East Broad Street, P.O. Box 980204, Richmond, VA 23298-0204, USA.

The authors discuss principles of continuous flow left ventricular assist device (LVAD) operation, basic differences between the axial and centrifugal flow designs and hemodynamic performance, normal LVAD physiology, and device interaction with the heart. Systematic interpretation of LVAD parameters and recognition of abnormal patterns of flow and pulsatility on the device interrogation are necessary for clinical assessment of the patient. Optimization of pump flow using LVAD parameters and echocardiographic and hemodynamics guidance are reviewed.
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http://dx.doi.org/10.1016/j.ccc.2018.03.002DOI Listing
July 2018

Solving the Puzzle of the Hematologic-Left Ventricular Assist Device Interface One Piece at a Time.

ASAIO J 2018 Jul/Aug;64(4):431-432

Virginia Commonwealth University Medical Center, Richmond, VA.

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http://dx.doi.org/10.1097/MAT.0000000000000848DOI Listing
March 2019
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