Publications by authors named "Nir Uriel"

365 Publications

Insights from a clinical heart valve centre: characteristics and management of functional mitral regurgitation.

Eur J Heart Fail 2022 Jul 6. Epub 2022 Jul 6.

Division of Adult Cardiac Surgery, Department of Surgery, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA.

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http://dx.doi.org/10.1002/ejhf.2614DOI Listing
July 2022

Hospitalization Patterns and Impact of a Magnetically-Levitated Left Ventricular Assist Device in the MOMENTUM 3 Trial.

JACC Heart Fail 2022 Jul 8;10(7):470-481. Epub 2022 Jun 8.

Center for Advanced Heart Disease, Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Background: In the MOMENTUM 3 (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3) pivotal trial, the HeartMate 3 (HM3) fully magnetically levitated left ventricular assist device (LVAD) demonstrated superiority over the axial-flow HeartMate II (HMII) LVAD. The patterns and predictors of hospitalizations with the HM3 LVAD have not been characterized.

Objectives: This study sought to determine causes, predictors, and impact of hospitalizations during LVAD support.

Methods: Patients discharged after LVAD implantation were analyzed. In the pivotal trial, 485 recipients of HM3 were compared with 471 recipients of HMII. The pivotal trial HM3 group was also compared to 949 recipients of HM3 in the postapproval phase within the trial portfolio. Predictors of cause-specific rehospitalization were analyzed.

Results: The rates of rehospitalization were lower with HM3 LVAD than with HMII LVAD in the pivotal trial (225.7 vs 246.4 events per 100 patient-years; P < 0.05). Overall, rehospitalization rates and duration were similar in the HM3 postapproval phase and pivotal trial but prolonged hospitalizations (>7 days) were less frequent (rate ratio: 0.90 [95% CI: 0.80-0.98]; P < 0.05). In HM3 recipients, the most frequent causes of rehospitalization included infection, heart failure (HF)-related events, and bleeding. First rehospitalization caused by HF-related event versus other causes was associated with reduced survival (HR: 2.2 [95% CI: 1.3-3.9]; P = 0.0014). Male sex, non-White race, presence of cardiac resynchronization therapy/implantable cardioverter-defibrillator, obesity, higher right atrial pressure, smaller LV size, longer duration of index hospitalization, and lower estimated glomerular filtration rate at index discharge predicted HF hospitalizations.

Conclusions: Contemporary support with the HM3 fully magnetically levitated LVAD is associated with a lower hospitalization burden than with prior pumps; however, rehospitalizations for infection, HF, and bleeding remain important challenges for progress in the patient journey. (MOMENTUM 3 IDE Clinical Study, NCT02224755; MOMENTUM 3 Continued Access Protocol [MOMENTUM 3 CAP], NCT02892955).
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http://dx.doi.org/10.1016/j.jchf.2022.03.007DOI Listing
July 2022

The role of temporary mechanical circulatory support as a bridge to advanced heart failure therapies or recovery.

Curr Opin Cardiol 2022 Jun 28. Epub 2022 Jun 28.

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

Purpose Of Review: Temporary mechanical circulatory support (tMCS) has become central in the treatment of refractory cardiogenic shock and can be used to bridge patients to durable MCS, heart transplant or recovery. This review will discuss contemporary data regarding bridging strategies utilizing tMCS.

Recent Findings: There has been significant growth in tMCS use recently, driven by increased familiarity with tMCS devices, and increased experience with both implantation and management. Identifying goals of therapy at the time of therapy initiation can facilitate better outcomes. The three primary goals are bridge to recovery, bridge to heart transplantation or bridge to durable left ventricular assist device. Bridging to recovery requires adequate treatment of underlying conditions and optimization of haemodynamics. Bridging to heart transplantation has become more frequent following changes to the heart allocation policy. Despite early concerns, patients bridge with tMCS, including ventricular-arterial extracorporeal membrane oxygenation, do not appear to have worse posttransplant outcomes. When bridging to durable mechanical circulatory support, tMCS can be used to enhance end-organ dysfunction and improve perioperative outcomes. In situations in which none of these goals are attainable, palliative care plays a critical role to identify patient wishes and assist with withdrawal of care when necessary.

Summary: The use of tMCS, as a bridge to recovery or heart replacement therapy in patients with refractory cardiogenic shock has grown significantly over the past decade. Multiple device choices are available and must be chosen appropriately to address the specific situation and the goals of therapy.
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http://dx.doi.org/10.1097/HCO.0000000000000976DOI Listing
June 2022

The difference between cystatin C- and creatinine-based assessment of kidney function in acute heart failure.

ESC Heart Fail 2022 Jun 27. Epub 2022 Jun 27.

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

Aims: Acute heart failure (HF) is associated with muscle mass loss, potentially leading to overestimation of kidney function using serum creatinine-based estimated glomerular filtration rate (eGFR ). Cystatin C-based eGFR (eGFR ) is less muscle mass dependent. Changes in the difference between eGFR and eGFR may reflect muscle mass loss. We investigated the difference between eGFR and eGFR and its association with clinical outcomes in acute HF patients.

Methods And Results: A post hoc analysis was performed in 841 patients enrolled in three trials: Diuretic Optimization Strategy Evaluation (DOSE), Renal Optimization Strategies Evaluation (ROSE), and Cardiorenal Rescue Study in Acute Decompensated Heart Failure (CARRESS-HF). Intra-individual differences between eGFRs (eGFR ) were calculated as eGFR -eGFR at serial time points during HF admission. We investigated associations of (i) change in eGFR between baseline and day 3 or 4 with readmission-free survival up to day 60; (ii) index hospitalization length of stay (LOS) and readmission with eGFR at day 60. eGFR reclassified 40% of samples to more advanced kidney dysfunction. Median eGFR was -4 [-11 to 1.5] mL/min/1.73 m at baseline, became more negative during admission and remained significantly different at day 60. The change in eGFR between baseline and day 3 or 4 was associated with readmission-free survival (adjusted hazard ratio per standard deviation decrease in eGFR : 1.14, P = 0.035). Longer index hospitalization LOS and readmission were associated with more negative eGFR at day 60 (both P ≤ 0.026 in adjusted models).

Conclusions: In acute HF, a marked difference between eGFR and eGFR is present at baseline, becomes more pronounced during hospitalization, and is sustained at 60 day follow-up. The change in eGFR during HF admission and eGFR at day 60 are associated with clinical outcomes.
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http://dx.doi.org/10.1002/ehf2.13975DOI Listing
June 2022

Predictors of 1-year outcome after cardiac re-transplantation: Machine learning analysis.

Clin Transplant 2022 Jun 22:e14761. Epub 2022 Jun 22.

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

Background: As cardiac re-transplantation is associated with inferior outcomes compared with primary transplantation, allocating scarce resources to appropriate re-transplant candidates is important. The aim of this study is to elucidate the factors associated with 1-year mortality in cardiac re-transplantation using the random forests algorithm for survival analysis.

Methods: We retrospectively reviewed the United Network for Organ Sharing registry and identified all adult (> 17 years old) recipients who underwent cardiac re-transplantation between January 2000 and March 2020. The random forest algorithm on Cox modeling was used to calculate the variable importance (VIMP) of independent variables for contributing to 1-year mortality.

Results: A total of 1294 patients underwent cardiac re-transplantation. Of these, 137 patients were re-transplanted within 1 year of their first transplant, while 1157 patients were re-transplanted more than 1 year after their first transplant. One-year mortality was significantly higher for patients receiving early transplantation compared with those receiving late transplantation (Early 40.6% vs. Late 13.6%, log-rank P < .001). Machine learning analysis showed that total bilirubin (> 2 mg/dl) (VIMP, 2.99%) was an independent predictor of 1-year mortality after early re-transplant. High BMI (> 30.0 kg/m ) (VIMP, 1.43%) and ventilator dependence (VIMP, 1.47%) were independent predictors of 1-year mortality for the late re-transplantation group.

Conclusion: Machine learning showed that optimal 1-year survival following cardiac re-transplantation was significantly related to liver function in early re-transplantation, and to obesity and preoperative ventilator dependence in late re-transplantation.
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http://dx.doi.org/10.1111/ctr.14761DOI Listing
June 2022

PCSK9 inhibitors safely and effectively lower LDL after heart transplantation: a systematic review and meta-analysis.

Heart Fail Rev 2022 Jun 10. Epub 2022 Jun 10.

Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, CT, USA.

Coronary allograft vasculopathy (CAV) continues to afflict a high number of heart transplant (HT) recipients, and elevated LDL is a key risk factor. Many patients cannot tolerate statin medications after HT; however, data for alternative agents remains scarce. To address this key evidence gap, we evaluated the safety and efficacy of the PCSK9i after HT through systematic review and meta-analysis. We searched Medline, Cochrane Central, and Scopus from the earliest date through July 15th, 2021. Citations were included if they were a report of PCSK9i use in adults after HT and reported an outcome of interest. Outcomes included change in LDL cholesterol from baseline, incidence of adverse events, and evidence of CAV. Changes from baseline and outcome incidences were pooled using contemporary random-effects model methodologies. A total of six studies including 97 patients were included. Over a mean follow-up of 13 months (range 3-21), PCSK9i use lowered LDL by 82.61 mg/dL (95% CI - 119.15 to - 46.07; I = 82%) from baseline. Serious adverse drug reactions were rarely reported, and none was attributable to the PCSK9i therapy. Four studies reported stable calcineurin inhibitor levels during PCSK9i initiation. One study reported outcomes in 33 patients with serial coronary angiography and intravascular ultrasound, and PCSK9i were associated with stable coronary plaque thickness and lumen area. One study reported on immunologic safety, showing no DSA development within 1 month of therapy. Preliminary data suggest that long-term PCSK9i therapy is safe, significantly lowers LDL, and may attenuate CAV after HT. Additional study on larger cohorts is warranted to confirm these findings.
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http://dx.doi.org/10.1007/s10741-022-10255-5DOI Listing
June 2022

Concurrent valvular procedures during left ventricular assist device implantation and outcomes: A comprehensive analysis of the Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3 trial portfolio.

J Thorac Cardiovasc Surg 2022 Apr 25. Epub 2022 Apr 25.

Center for Advanced Heart Disease, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass. Electronic address:

Background: Correction of valvular disease is often undertaken during left ventricular assist device (LVAD) implantation with uncertain benefit. We analyzed clinical outcomes with HeartMate 3 (HM3; Abbott) LVAD implantation in those with various concurrent valve procedures (HM3+VP) with those with an isolated LVAD implant (HM3 alone).

Methods: The study included 2200 patients with HM3 implanted within the Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3 (MOMENTUM 3) trial portfolio who underwent 820 concurrent procedures among which 466 (21.8%) were HM3+VP. VPs included 101 aortic, 61 mitral, 163 tricuspid; 85 patients had multiple VPs. Perioperative complications, major adverse events, and survival were analyzed.

Results: Patients who underwent HM3+VP had higher-acuity Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles (1-2: 41% vs 31%) compared with no VPs (P < .05). The cardiopulmonary bypass time (124 vs 76 minutes; P < .0001) and hospital length of stay (20 vs 18 days; P < .0001) were longer in HM3+VP. A higher incidence of stroke (4.9% vs 2.4%), bleeding (33.9% vs 23.8%), and right heart failure (41.5% vs 29.6%) was noted in HM3+VP at 0 to 30 days (P < .01), with no difference in 30-day mortality (3.9% vs 3.3%) or 2-year survival (81.7% vs 80.8%). Analysis of individual VP showed no differences in survival compared to HM3 alone. No differences were noted among patients with either significant mitral (moderate or worse) or tricuspid (moderate or worse) regurgitation with or without corrective surgery.

Conclusions: Concurrent VPs, commonly performed during LVAD implantation, are associated with increased morbidity during the index hospitalization, with no effect on short- and long-term survival. There is sufficient equipoise to consider a randomized trial on the benefit of commonly performed VPs (such as mitral or tricuspid regurgitation correction), during LVAD implantation.
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http://dx.doi.org/10.1016/j.jtcvs.2022.04.021DOI Listing
April 2022

Deep vein thrombosis and pulmonary embolism after heart transplantation.

Clin Transplant 2022 Jul 20;36(7):e14705. Epub 2022 May 20.

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

Introduction: Venous thromboembolism (VTE), such as deep vein thrombosis (DVT) and pulmonary embolism (PE), is an important and serious postoperative complication after heart transplantation. We sought to characterize in-hospital VTE after heart transplantation and its association with clinical outcomes.

Method: Adult (≧18 years) patients undergoing heart transplantation from 2015 to 2019 at our center were retrospectively reviewed. Post-transplant VTE was defined as newly diagnosed venous system thrombus by imaging studies.

Results: There were 254 patients. The cohort's median age was 55 years. A total of 61 patients were diagnosed with VTE, including one with right atrial thrombus, 54 with upper extremity DVT in which one patient subsequently developed PE, four with lower extremity DVT, and two with upper and lower extremity DVT. The cumulative incidence of VTE was 42% at 60-days of post heart transplant. Patients with VTE had longer hospital stay (P < .001), higher in-hospital mortality (P = .010), and worse 5-year survival (P = .009). On the multivariable Cox analysis, history of DVT/PE and intubation for more than 3 days were associated with an increased risk of in hospital VTE.

Conclusion: The incidence of VTE in heart transplant recipients is high. Post-transplant surveillance, and appropriate preventive measures and treatment strategies after diagnosis are warranted.
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http://dx.doi.org/10.1111/ctr.14705DOI Listing
July 2022

Center Variability in Patient Outcomes Following HeartMate 3 Implantation: An Analysis of the MOMENTUM 3 Trial.

J Card Fail 2022 Jul 30;28(7):1158-1168. Epub 2022 Apr 30.

Henry Ford Hospital, Detroit, Michigan.

Background: As left ventricular assist device (LVAD) survival rates continue to improve, evaluating site-specific variability in outcomes can facilitate identifying targets for quality-improvement initiative opportunities in the field.

Methods: Deidentified center-specific outcomes were analyzed for HeartMate 3 (HM3) patients enrolled in the MOMENTUM 3 pivotal and continued access protocol trials. Centers < 25th percentile for HM3 volumes were excluded. Variability in risk-adjusted center mortality was assessed at 90 days and 2 years (conditional upon 90-day survival). Adverse event (AE) rates were compared across centers.

Results: In the 48 included centers (1958 patients), study-implant volumes ranged between 17 and 106 HM3s. Despite similar trial-inclusion criteria, patient demographics varied across sites, including age quartile ((Q)1-Q3:57-62 years), sex (73%-85% male), destination therapy intent (60%-84%), and INTERMACS profile 1-2 (16%-48%). Center mortality was highly variable, nadiring at ≤ 3.6% (≤ 25th percentile) and peaking at ≥ 10.4% (≥ 75th percentile) at 90 days and ≤ 10.2% and ≥ 18.7%, respectively, at 2 years. Centers with low mortality rates tended to have lower 2-year AE rates, but no center was a top performer for all AEs studied.

Conclusions: Mortality and AEs were highly variable across MOMENTUM 3 centers. Studies are needed to improve our understanding of the drivers of outcome variability and to ascertain best practices associated with high-performing centers across the continuum of intraoperative to chronic stages of LVAD support.
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http://dx.doi.org/10.1016/j.cardfail.2022.04.006DOI Listing
July 2022

Outcomes in Smaller Body Size Adults After HeartMate 3 Left Ventricular Assist Device Implantation.

Ann Thorac Surg 2022 Apr 19. Epub 2022 Apr 19.

Department of Surgery, Columbia University College of Physicians and Surgeons and NewYork-Presbyterian Hospital, New York, New York.

Background: Outcomes in patients with smaller body size after HeartMate 3 left ventricular assist device (HM3) implantation are not well characterized. We sought to evaluate outcomes in smaller vs larger body surface area (BSA) patients in the MOMENTUM 3 pivotal trial and its Continued Access Protocol cohort.

Methods: The analysis cohort included 1015 HM3 patients divided into 2 groups: BSA ≤1.70 m (small patients, n = 82) and BSA >1.70 m (large patients, n = 933). The composite primary end point was survival at 2 years free of disabling stroke or reoperation to replace or to remove a malfunctioning device. Adverse events were compared between groups.

Results: Smaller patients were more frequently women (56.1% vs 17.7%; P < .001) and had lower prevalence of diabetes (28.1% vs 43.9%; P = .005) and hypertension (51.2% vs 71.9%; P < .001), larger median indexed LVEDD (normalized by BSA, 40 vs 33 mm/m; P < .001), and lower median serum creatinine concentration (1.1 vs 1.3 mg/dL; P < .001). The proportion of patients achieving the composite end point at 2 years was 77% in both groups (adjusted hazard ratio, 1.14; 95% CI, 0.68-1.91; P = .62). Two-year adverse event rates were also similar between groups except for sepsis (6.1% vs 14.9%; P = .029) and cardiac arrhythmias (24.4% vs 35.3%; P = .005), which were higher in the larger patients.

Conclusions: Outcomes after HM3 implantation were comparable between small and large patients. Smaller body size should not be used to deny HM3 implantation in patients who are otherwise suitable candidates for durable mechanical circulatory support.
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http://dx.doi.org/10.1016/j.athoracsur.2022.03.071DOI Listing
April 2022

Twenty-four-hour blood pressure and heart rate variability are reduced in patients on left ventricular assist device support.

J Heart Lung Transplant 2022 06 27;41(6):802-809. Epub 2022 Feb 27.

Division of Cardiology, Columbia University Medical Center, New York, New York. Electronic address:

Background: Limited data exist on the circadian blood pressure (BP) and heart rate (HR) variations that occur in heart failure (HF) patients on left ventricular assist device (LVAD) support.

Methods: We prospectively recorded clinic and 24-hour ambulatory BP and HR data in patients on HeartMate II LVAD support. Results were compared to HF patients with ejection fraction ≤30% and controls with no history of cardiovascular disease. Physiologic nocturnal BP and HR dipping was defined as a ≥10% decline compared to daytime values.

Result: Twenty-nine LVAD patients (age 59 ± 15 years, 76% male, 38% ischemic etiology), 25 HF patients (age 64 ± 13 years, 84% male, 32% ischemic etiology) and 26 controls (age 56 ± 9 years, 62% male) were studied. Normal nocturnal BP dipping was less frequent in LVAD patients (10%) than in HF patients (28%) and controls (62%) and reversed BP dipping (BP increase at night) was more common in LVAD patients (24%), compared to HF (16%) and controls (8%), (p < 0.001, for all comparisons). Physiologic HR reduction was less frequent in LVAD patients (14%), compared to HF (16%) and controls (59%) (p < 0.001, for all comparisons). Among LVAD patients, 36% exhibited sustained hypertension over the 24-hours and 25% had white-coat hypertension.

Conclusions: Treatment of advanced HF with an LVAD does not restore physiologic circadian variability of BP and HR; additionally, BP was not adequately controlled in more than a third of LVAD patients, and a quarter of them exhibited white-coat hypertension. Future studies are warranted to confirm these findings and investigate prognostic and management implications in this population.
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http://dx.doi.org/10.1016/j.healun.2022.02.016DOI Listing
June 2022

The use of telemedicine in cardiogenetics clinical practice during the COVID-19 pandemic.

Mol Genet Genomic Med 2022 06 7;10(6):e1946. Epub 2022 Apr 7.

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

Background: The COVID-19 pandemic has necessitated the rapid and widespread adoption of novel mechanisms of service delivery, including the use of telemedicine. The aim of this study was to examine the impact of COVID-19 on cardiogenetics practices.

Methods: We retrospectively analyzed the clinical characteristics of patients who were seen for cardiogenetics visits pre-pandemic (1 April-23 December 2019) and during the pandemic (1 April-23 December 2020) at Columbia University Irving Medical Center.

Results: Six percent (n = 6) of visits in 2019 were remote telemedicine encounters, whereas 80% (n = 106) of visits in 2020 were telemedicine encounters. In 2019, only 18% (n = 19) of the patients seen for genetic counseling were family members of probands; this percentage increased to 34% in 2020 (n = 45; p = .01). In 2020, the geographic reach of genetic counseling also extended far beyond New York State, reaching a total of 11 states as well as one patient in Puerto Rico. Genetic testing results were similar in 2019 and 2020.

Conclusion: Despite the health-care delivery barriers created by the COVID-19 pandemic, the use of telemedicine allowed us to expand the reach of cardiovascular genetic counseling and testing.
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http://dx.doi.org/10.1002/mgg3.1946DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9184656PMC
June 2022

Predictors of Survival and Ventricular Recovery Following Acute Myocardial Infarction Requiring Extracorporeal Membrane Oxygenation Therapy.

ASAIO J 2022 06 19;68(6):800-807. Epub 2022 Jan 19.

Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) following acute myocardial infarction with cardiogenic shock (AMI-CS) is increasing, but the ability to predict favorable outcomes with support remains limited. We retrospectively reviewed all patients with AMI-CS supported with VA-ECMO between December 2008 and June 2018. One hundred twenty-six patients received VA-ECMO for AMI-CS during the study period; of these, 39 (31.0%) experienced ventricular recovery and were discharged while 87 (69.0%) did not recover, with 71 (56.3%) dying in the hospital and 16 (12.7%) surviving to discharge with either left ventricular assist device or heart transplant. TIMI 3 flow in culprit artery (OR, 4.01; 95% CI, 1.25-12.77; p = 0.02), serum lactate (OR, 0.89; 95% CI, 0.80-0.99; p = 0.04), and prompt revascularization (OR, 3.39; 95% CI, 1.18-9.81; p = 0.02) were independent predictors of ventricular recovery. Four variables emerged as independent predictors of in-hospital mortality and were used to create the AMI-ECMO Risk Score: age >70 years, creatinine >1.5 mg/dL, serum lactate > 4.0 mmol/L, and lack of TIMI 3 flow in culprit artery. In patients supported with VA-ECMO for AMI-CS, prompt, successful revascularization, and lower serum lactate were associated with ventricular recovery while younger age, lower serum lactate, and creatinine, and successful revascularization were associated with survival to discharge. The AMI-ECMO risk score is a simple tool that can help risk stratify patients with AMI-CS being considered for VA-ECMO support.
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http://dx.doi.org/10.1097/MAT.0000000000001570DOI Listing
June 2022

Impact of socioeconomic deprivation on evaluation for heart transplantation at an urban academic medical center.

Clin Transplant 2022 Jun 3;36(6):e14652. Epub 2022 May 3.

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

Introduction: For patients with advanced heart failure, socioeconomic deprivation may impede referral for heart transplantation (HT). We examined the association of socioeconomic deprivation with listing among patients evaluated at our institution and compared this against the backdrop of our local community.

Methods: We conducted a retrospective cohort study of patients evaluated for HT between January 2017 and December 2020. Patient demographics and clinical characteristics were recorded. Block group-level area deprivation index (ADI) decile was obtained at each patient's home address and Socioeconomic Status (SES) index was determined by patient zip code.

Results: In total, 400 evaluations were initiated; one international patient was excluded. Among this population, 111 (27.8%) were women, 219 (54.9%) were White, 94 (23.6%) Black, and 59 (14.8%) Hispanic. 248 (62.2%) patients were listed for transplant. Listed patients had significantly higher SES index and lower ADI compared to those who were not listed. However, after adjustment for clinical factors, ADI and SESi were not predictive of listing. Similarly, patient sex, race, and insurance did not influence the likelihood of listing for HT. Notably, the distribution of the referral cohort based on ADI deciles was not reflective of our center's catchment area, indicating opportunities for improving access to transplant for disadvantaged populations.

Conclusions: Although socioeconomic deprivation did not predict listing in our analysis, we recognize the need for broader outreach to combat upstream bias that prevents patients from being referred for HT.
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http://dx.doi.org/10.1111/ctr.14652DOI Listing
June 2022

Fulminant Giant Cell Myocarditis Requiring Bridge With Mechanical Circulatory Support to Heart Transplantation.

JACC Case Rep 2022 Mar 2;4(5):265-270. Epub 2022 Mar 2.

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

Giant cell myocarditis is a rare cause of cardiogenic shock requiring a high index of suspicion, rapid immunosuppressive therapy, and mechanical circulatory support. We present the case of a patient with giant cell myocarditis who underwent a successful bridge with four different types of mechanical circulatory support devices to heart transplantation. ().
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http://dx.doi.org/10.1016/j.jaccas.2021.11.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8897036PMC
March 2022

Recovery With Temporary Mechanical Circulatory Support While Waitlisted for Heart Transplantation.

J Am Coll Cardiol 2022 03;79(9):900-913

Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, Utah, USA.

Background: The 2018 U.S. heart allocation system offers an accelerated pathway for heart transplantation to the most urgent patients.

Objectives: This study sought to determine whether the new allocation system resulted in lower likelihood of candidate recovery.

Methods: Adult patients waitlisted for heart transplantation with temporary mechanical circulatory support at the time of initial listing between 2010 and 2020 in the United Network for Organ Sharing registry were included. Competing events of heart transplantation, waitlist death or delisting for deteriorating condition, and delisting for improved condition (candidate recovery) were analyzed in the new vs old heart allocation system.

Results: A total of 688 patients were waitlisted with venoarterial extracorporeal membrane oxygenation or a surgical nondischargeable biventricular assist device (status 1 or old 1A). Overall, 2,237 patients were waitlisted with an intra-aortic balloon pump, a percutaneous left ventricular assist device (LVAD), or a surgical nondischargeable LVAD (status 2 or old 1A). Patients waitlisted with venoarterial extracorporeal membrane oxygenation or a nondischargeable biventricular assist device had significantly shorter median waitlist times (5 vs 31 days), higher incidence for cardiac transplantation (81.5% vs 43.0%), and lower incidence of candidate recovery (1.5% vs 7.9%) in the new vs old heart allocation system (all P < 0.05). Patients waitlisted with an intra-aortic balloon pump or percutaneous or a nondischargeable LVAD also had significantly shorter median waitlist times (8 vs 35 days), higher incidence of transplantation (88.9% vs 64.9%), and lower incidence of candidate recovery (0.2% vs 1.6%) in the new vs old heart allocation system (all P < 0.05).

Conclusions: Current practice of the new allocation system may not offer select temporary mechanical circulatory support patients the opportunity and adequate time to recover to the point of waitlist removal. Further research will determine which patients would benefit from urgent transplantation vs recovery strategy.
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http://dx.doi.org/10.1016/j.jacc.2021.12.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8928585PMC
March 2022

Driveline Infection in Left Ventricular Assist Device Patients: Effect of Standardized Protocols, Pathogen Type, and Treatment Strategy.

ASAIO J 2022 Mar 1. Epub 2022 Mar 1.

From the Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York Department of Surgery, Division of Cardiac Surgery, Columbia University Irving Medical Center, New York, New York Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York Department of Medicine Division of Infectious Diseases, Columbia University Irving Medical Center, New York, New York. Paolo C. Colombo and Melana Yuzefpolskaya contributed equally to this study.

Driveline infection (DLI) is common after left ventricular assist device (LVAD). Limited data exist on DLI prevention and management. We investigated the impact of standardized driveline care initiatives, specific pathogens, and chronic antibiotic suppression (CAS) on DLI outcomes. 591 LVAD patients were retrospectively categorized based on driveline care initiatives implemented at our institution (2009-2019). Era (E)1: nonstandardized care; E2: standardized driveline care protocol; E3: addition of marking driveline exit site; E4: addition of "no shower" policy. 87(15%) patients developed DLI at a median (IQR) of 403(520) days. S. aureus and P. aeruginosa were the most common pathogens. 31 (36%) of DLI patients required incision and drainage (I&D) and 5 (5.7%) device exchange. P. aeruginosa significantly increased risk for initial I&D (HR 2.7, 95% CI, 1.1-6.3) and recurrent I&D or death (HR 4.2, 95% CI, 1.4-12.5). Initial I&D was associated with a significant increased risk of death (HR 2.92 (1.33-6.44); P = 0.008) when compared to patients who did not develop DLI. Implementation of standardized driveline care protocol (E2) was associated with increased 2-year freedom from DLI compared to nonstandardized care (HR 0.36, 95% CI, 0.2-0.6, P < 0.01). Additional preventive strategies (E3&E4) showed no further reduction in DLI rates. 57(65%) DLI patients received CAS, 44% of them required escalation to intravenous antibiotics and/or I&D. Presence of P. aeruginosa DLI markedly increased risk for I&D or death. Conditional survival of patients progressing to I&D is diminished. Standardized driveline care protocol was associated with a significant reduction in DLI, while additional preventive strategies require further testing.
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http://dx.doi.org/10.1097/MAT.0000000000001690DOI Listing
March 2022

Continuous Monitoring of Blood Pressure Using a Wrist-Worn Cuffless Device.

Am J Hypertens 2022 05;35(5):407-413

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

Background: Measuring an accurate blood pressure (BP) in ambulatory patients is critical for therapeutic decisions. An accurate noninvasive device that measures BP continuously could provide a more comprehensive assessment of BP. The aim of this study was to determine whether the LiveOne device, a cuffless wristband that provides continuous BP measurements, is accurate in comparison to an invasive arterial line (A-line).

Methods: We enrolled hospitalized patients and healthy volunteers in this multicenter study. All patients had an invasive A-line. Waveforms were simultaneously downloaded from the A-line and LiveOne device. The primary outcome was the correlation between the LiveOne device and the A-line for systolic BP (SBP) and diastolic BP (DBP).

Results: Thirty-four patients with 233 measurement periods were included. Mean age was 60.7 ± 15.2 years, and 15 (44%) were female. The correlation for SBP was 0.91 and for DBP was 0.85. The mean band error was 0.0 ± 6.9 mm Hg for SBP and 1.2 ± 5.7 mm Hg for DBP. The mean absolute error was 8.2 ± 5.8 mm Hg for SBP and 6.4 ± 3.9 mm Hg for DBP. For SBP, 98% of LiveOne measurements were within 15 mm Hg and for DBP, 92% of LiveOne measurements were within 10 mm Hg.

Conclusions: The LiveOne device provides continuous, noninvasive BP measurements that are accurate in comparison to A-line measurements. The portability and unobtrusive nature of this device and the ability to provide continuous BP measurements may offer advantages over currently available BP monitors.

Clinical Trials Registration: Trial Number NCT03919136.
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http://dx.doi.org/10.1093/ajh/hpac020DOI Listing
May 2022

Impact of Pretransplant Malignancy on Heart Transplantation Outcomes: Contemporary United Network for Organ Sharing Analysis Amidst Evolving Cancer Therapies.

Circ Heart Fail 2022 04 31;15(4):e008968. Epub 2022 Jan 31.

Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY.

Background: An aging population and improved cancer survivorship have increased the number of individuals with treated malignancy who develop advanced heart failure. The benefits of heart transplantation (HT) in patients with a pretransplant malignancy (PTM) must be balanced against risks of posttransplant malignancy in the setting of immunosuppression.

Methods: Adult patients in the United Network for Organ Sharing registry who received HT between January 1, 2010, and December 31, 2020 were included. Trends, patient characteristics, and posttransplant outcomes in HT recipients with PTM were evaluated.

Results: From 2000 to 2020, the proportion of HT recipients with PTM increased from 3.2% to 8.2%. From 2010 to 2020, 2113 (7.7%) of 27 344 HT recipients had PTM. PTM was associated with higher rates of 1-year mortality after HT (11.9% versus 9.2%; adjusted hazard ratio, 1.25 [95% CI, 1.09-1.44], =0.001), driven by increased mortality in patients with hematologic PTM (adjusted hazard ratio, 2.00 [95% CI, 1.61-2.48]; <0.001). For recipients who survived the first year, 5-year survival was similar between patients with and without PTM. Rates of malignancy at 5-years posttransplant were higher in the PTM group (20.4% versus 13.1%; adjusted hazard ratio, 1.57 [95% CI, 1.38-1.79], <0.001).

Conclusions: Prevalence of PTM in HT recipients nearly tripled over the past 2 decades. Patients with hematologic PTM were at increased risk of early mortality after HT. Patients with PTM were also at higher risk for posttransplant malignancy. Guidelines that reflect contemporary oncological care are needed to inform care of this heterogenous and expanding group of individuals.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.121.008968DOI Listing
April 2022

Outflow Graft Narrowing of the HeartMate 3 Left Ventricular Assist Device.

Ann Thorac Surg 2022 Jan 6. Epub 2022 Jan 6.

Division of Cardiology, New York-Presbyterian, Columbia University Medical Center, New York, New York.

Background: In patients with the HeartMate 3 (HM3, Abbott) left ventricular (LV) assist device (LVAD), outflow graft narrowing has been reported as a result of accumulation of biodebris either internal or external to the graft. This study describes the prevalence, imaging findings, and clinical outcomes associated with HM3 LVAD outflow graft narrowing.

Methods: A single-center retrospective cohort study was performed in patients who received an HM3 LVAD between November 2014 and July 2019. All patients with a computed tomographic (CT) angiogram or a CT scan with intravenous contrast sufficient to evaluate the outflow graft lumen were included. Narrowing was defined as a hypodensity of ≥3 mm.

Results: Of 165 HM3 LVAD recipients, 46 (28%) had qualifying imaging. Outflow graft narrowing was present in 33% (15/46). One patient had complete obstruction requiring emergency surgery, whereas 14 patients had a median hypodensity of 4.5 mm (interquartile range, 3.3-5.8 mm). The presence of outflow graft narrowing was significantly associated with a longer duration of LVAD support (588.2 ± 277.5 days vs 131.5 ± 170.9 days; P < .0001). One-year survival after identification of narrowing was 93%, with death occurring in 1 patient with complete obstruction. LV unloading (mean percent decrease in LV end-diastolic diameter at time of CT imaging vs pre-LVAD) was 16.7% vs 17.7% in patients with and without narrowing, respectively (P = .86).

Conclusions: Among patients with adequate imaging, one-third have evidence of narrowing. Outflow graft narrowing secondary to biodebris was more likely to be found in HM3 LVAD recipients with longer duration of LVAD support. There was no significant difference in LV unloading between patients with and without narrowing.
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http://dx.doi.org/10.1016/j.athoracsur.2021.12.014DOI Listing
January 2022

Impact of Temporary Percutaneous Mechanical Circulatory Support Before Transplantation in the 2018 Heart Allocation System.

JACC Heart Fail 2022 01 10;10(1):12-23. Epub 2021 Nov 10.

Milstein Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA. Electronic address:

Objectives: This analysis sought to investigate the waitlist and post-transplant outcomes of individuals bridged to transplantation by using temporary percutaneous endovascular mechanical circulatory support (tMCS) through a status 2 designation (cardiogenic shock and exception).

Background: The 2018 donor heart allocation policy change granted a status 2 designation to patients supported with tMCS.

Methods: Adult patients in the United Network for Organ Sharing registry after October 18, 2018 who received a status 2 designation for tMCS were included and grouped by their status 2 criteria: cardiogenic shock with hemodynamic criteria (CS-HD), cardiogenic shock without hemodynamic criteria before tMCS (CS-woHD), and exception. Baseline characteristics, waitlist events (death and delisting), and post-transplant outcomes were compared.

Results: A total of 2,279 patients met inclusion criteria: 68.6% (n = 1,564) with CS-HD, 3.2% (n = 73) with CS-woHD, and 28.2% (n = 642) with exceptions. A total of 64.2% of patients underwent heart transplantation within 14 days of status 2 listing or upgrade, and 1.9% died or were delisted for worsening clinical condition. Among the 35.8% who did not undergo transplantation following 14 days, only 2.8% went on to receive a left ventricular assist device (LVAD). The 30-day transplantation likelihood was similar among groups: 80.1% for the CS-HD group vs 79.7% for the exception group vs 73.3% for the CS-woHD group; P = 0.31. However, patients who met criteria for CS-woHD had 2.3-fold greater risk of death or delisting (95% CI: 1.10-4.75; P = 0.03) compared with CS-HD patients after multivariable adjustment. Pre-tMCS hemodynamics were not associated with adverse waitlist events.

Conclusions: The use of tMCS is an efficient, safe, and effective strategy as a bridge to transplantation; however, patients with CS-woHD may represent a high-risk cohort. Transition to a durable LVAD was a rare event in this group.
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http://dx.doi.org/10.1016/j.jchf.2021.08.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8724562PMC
January 2022

Remote Cardiac Monitoring in Patients With Heart Failure: A Review.

JAMA Cardiol 2022 05;7(5):556-564

Division of Cardiology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York.

Importance: Heart failure (HF) is often characterized by an insidious disease course leading to frequent rehospitalizations and a high use of ambulatory care. Remote cardiac monitoring is a promising approach to detect worsening HF early and intervene prior to an overt decompensation.

Observations: Recently, a multitude of novel technologies for remote cardiac monitoring (RCM) in patients with HF have been developed and are undergoing clinical trials. This development has been accelerated by the COVID-19 pandemic.

Conclusions And Relevance: This review summarizes the major clinical trials on RCM in patients with HF and present the most recent developments in noninvasive and invasive RCM technologies.
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http://dx.doi.org/10.1001/jamacardio.2021.5090DOI Listing
May 2022

Invasive Right Ventricular Pressure-Volume Analysis: Basic Principles, Clinical Applications, and Practical Recommendations.

Circ Heart Fail 2022 01 29;15(1):e009101. Epub 2021 Dec 29.

Division of Cardiology, Columbia University Medical Center, New York, NY (M.I.B., A.M., V.G.N., R.T.H., S.K.K., G.T.S., N.U., D.B.).

Right ventricular pressure-volume (PV) analysis characterizes ventricular systolic and diastolic properties independent of loading conditions like volume status and afterload. While long-considered the gold-standard method for quantifying myocardial chamber performance, it was traditionally only performed in highly specialized research settings. With recent advances in catheter technology and more sophisticated approaches to analyze PV data, it is now more commonly used in a variety of clinical and research settings. Herein, we review the basic techniques for PV loop measurement, analysis, and interpretation with the aim of providing readers with a deeper understanding of the strengths and limitations of PV analysis. In the second half of the review, we detail key scenarios in which right ventricular PV analysis has influenced our understanding of clinically relevant topics and where the technique can be applied to resolve additional areas of uncertainty. All told, PV analysis has an important role in advancing our understanding of right ventricular physiology and its contribution to cardiovascular function in health and disease.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.121.009101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8766922PMC
January 2022

Machine Learning-Based Prediction of Myocardial Recovery in Patients With Left Ventricular Assist Device Support.

Circ Heart Fail 2022 01 24;15(1):e008711. Epub 2021 Dec 24.

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

Background: Prospective studies demonstrate that aggressive pharmacological therapy combined with pump speed optimization may result in myocardial recovery in larger numbers of patients supported with left ventricular assist device (LVAD). This study sought to determine whether the use of machine learning (ML) based models predict LVAD patients with myocardial recovery resulting in pump explant.

Methods: A total of 20 270 adult patients with a durable continuous-flow LVAD in the INTERMACS registry (Interagency Registry for Mechanically Assisted Circulatory Support) were included in the study. Ninety-eight raw clinical variables were screened using the least absolute shrinkage and selection operator for selection of features associated with LVAD-induced myocardial recovery. ML models were developed in the training data set (70%) and were assessed in the validation data set (30%) by receiver operating curve and Kaplan-Meier analysis.

Results: Least absolute shrinkage and selection operator identified 28 unique clinical features associated with LVAD-induced myocardial recovery, including age, cause of heart failure, psychosocial risk factors, laboratory values, cardiac rate and rhythm, and echocardiographic indices. ML models achieved area under the receiver operating curve of 0.813 to 0.824 in the validation data set outperforming logistic regression-based new INTERMACS recovery risk score (area under the receiver operating curve of 0.796) and previously established LVAD recovery risk scores (INTERMACS Cardiac Recovery Score and INTERMACS Recovery Score by Topkara et al) with area under the receiver operating curve of 0.744 and 0.748 (<0.05). Patients who were predicted to recover by ML models demonstrated a significantly higher incidence of myocardial recovery resulting in LVAD explant in the validation cohort compared with those who were not predicted to recover (18.8% versus 2.6% at 4 years of pump support).

Conclusions: ML can be a valuable tool to identify subsets of LVAD patients who may be more likely to respond to myocardial recovery protocols.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.121.008711DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8766904PMC
January 2022

Surveillance for disease progression of transthyretin amyloidosis after heart transplantation in the era of novel disease modifying therapies.

J Heart Lung Transplant 2022 02 25;41(2):199-207. Epub 2021 Oct 25.

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

Background: Heart Transplantation (HT) is a rational therapy for advanced transthyretin cardiac amyloidosis (ATTR-CA), but the impact of ongoing amyloid deposition is not well defined. We evaluated a cohort of patients who underwent HT for ATTR-CA to determine the incidence of de novo or progression of post-HT ATTR deposition.

Methods: All patients who were followed post-HT for ATTR-CA at our center were included. Baseline demographics and post-HT manifestations of TTR deposition were collected. All patients completed the Composite Autonomic Symptom Score (COMPASS-31 quantifies autonomic symptoms, with a higher score [0-100] indicating more severe autonomic dysfunction) and Polyneuropathy Disability Score (PND, range from 0 [asymptomatic] to IV [confined to wheelchair/bed]) questionnaires.

Results: Twelve patients (5 wild-type, 7 variant [6 p.Val142Ile, 1 p.Thr80Ala]) were included. Mean age at HT was 64.6 (SD: 4.8) years, 83.3% male, and 50% Black. At a median of 4.0 years (IQR 2.4, 5.9) post-HT, 8 patients had symptoms of ATTR deposition (5 with gastrointestinal involvement, 4 orthopedic and 4 neurologic), with 4 patients having ≥2 body systems involved. There were no patients with recurrent cardiac involvement. Median COMPASS-31 score was 17.3 (IQR 11.3, 23.5) at 3.9 years (IQR 2.4, 5.9) post-HT. Four patients had a PND score of stage 1 (sensory disturbance), 1 patient was stage 2 (impaired walking) and 1 patient stage 3b (required a walking aid).

Conclusions: More than 50% of patients had evidence of progressive or de novo ATTR deposition post-HT, impairing quality of life despite a well-functioning cardiac allograft. These observations highlight an unmet need to establish the role of formal surveillance and treatment of TTR using TTR disease-modifying therapies, which may maintain or improve quality of life post-HT for ATTR-CA.
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http://dx.doi.org/10.1016/j.healun.2021.10.007DOI Listing
February 2022

First Transfemoral Implantation of a Novel Transcatheter Valve in an LVAD Patient With Aortic Insufficiency.

JACC Case Rep 2021 Dec 1;3(17):1806-1810. Epub 2021 Dec 1.

Structural Heart and Valve Center, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, USA.

An 80-year-old man with a destination left ventricular assist device (LVAD) presented with decompensated heart failure. Evaluation demonstrated numerous LVAD high power spike events, significant aortic regurgitation, and hemolysis. He underwent successful aortic valve replacement with a novel transcatheter valve and LVAD pump exchange that resulted in an improvement in his clinical status. ().
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http://dx.doi.org/10.1016/j.jaccas.2021.08.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8642726PMC
December 2021

Clinico-histopathologic and single-nuclei RNA-sequencing insights into cardiac injury and microthrombi in critical COVID-19.

JCI Insight 2022 01 25;7(2). Epub 2022 Jan 25.

Division of Cardiology, Columbia University Irving Medical Center (CUIMC), New York, New York, USA.

Acute cardiac injury is prevalent in critical COVID-19 and associated with increased mortality. Its etiology remains debated, as initially presumed causes - myocarditis and cardiac necrosis - have proved uncommon. To elucidate the pathophysiology of COVID-19-associated cardiac injury, we conducted a prospective study of the first 69 consecutive COVID-19 decedents at CUIMC in New York City. Of 6 acute cardiac histopathologic features, presence of microthrombi was the most commonly detected among our cohort. We tested associations of cardiac microthrombi with biomarkers of inflammation, cardiac injury, and fibrinolysis and with in-hospital antiplatelet therapy, therapeutic anticoagulation, and corticosteroid treatment, while adjusting for multiple clinical factors, including COVID-19 therapies. Higher peak erythrocyte sedimentation rate and C-reactive protein were independently associated with increased odds of microthrombi, supporting an immunothrombotic etiology. Using single-nuclei RNA-sequencing analysis on 3 patients with and 4 patients without cardiac microthrombi, we discovered an enrichment of prothrombotic/antifibrinolytic, extracellular matrix remodeling, and immune-potentiating signaling among cardiac fibroblasts in microthrombi-positive, relative to microthrombi-negative, COVID-19 hearts. Non-COVID-19, nonfailing hearts were used as reference controls. Our study identifies a specific transcriptomic signature in cardiac fibroblasts as a salient feature of microthrombi-positive COVID-19 hearts. Our findings warrant further mechanistic study as cardiac fibroblasts may represent a potential therapeutic target for COVID-19-associated cardiac microthrombi.
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http://dx.doi.org/10.1172/jci.insight.154633DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8855793PMC
January 2022

Impact of UNOS allocation policy changes on utilization and outcomes of patients bridged to heart transplant with intra-aortic balloon pump.

Clin Transplant 2022 02 28;36(2):e14533. Epub 2021 Nov 28.

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

Objective: Intra-aortic balloon pump (IABP) support may improve the hemodynamic profiles of patients in cardiogenic shock and bridge patients to heart transplant. In 2018, the United Network for Organ Sharing (UNOS) introduced new heart allocation criteria that increased the waitlist status of patients with IABPs to Status 2. This study assesses the impact of this change on IABP use and outcomes of patients with IABPs.

Methods: We queried the UNOS database for first adult heart transplant candidates with IABPs listed or transplanted before and after the UNOS policy changes (October 18, 2016-October 17, 2018, or October 18, 2018-September 4, 2020). We compared post-transplant survival and waitlist outcomes using Kaplan-Meier and Fine-Gray analyses.

Results: Two thousand three hundred fifty-eight patients met inclusion criteria. Utilization of IABPs for hemodynamic support increased by 338% in the two years after the policy change. Patients with IABPs listed after the policy change were more likely to receive a transplant and were transplanted more quickly (p < .001). Posttransplant survival was comparable before and after the policy change (p = .056), but non-transplanted patients were more likely to be delisted post-policy change (p < .001).

Conclusion: The UNOS allocation criteria have benefited patients bridged with an IABP, given the higher transplant rate and shorter time to transplant.
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http://dx.doi.org/10.1111/ctr.14533DOI Listing
February 2022

Chronic intermittent intravenous immunoglobulin in heart transplant recipients with elevated donor-specific antibody levels.

Clin Transplant 2022 02 9;36(2):e14524. Epub 2021 Nov 9.

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

Donor-specific antibodies (DSA) are associated with antibody-mediated rejection (AMR) and poor patient survival. In heart transplant, the efficacy of intermittent intravenous immunoglobulin (IVIg) in reducing de novo DSA levels and treating AMR has not been characterized. We retrospectively studied a cohort of 19 patients receiving intermittent IVIg for elevated DSA and examined changes in DSA levels and graft function. Intermittent IVIg infusions were generally safe and well tolerated. Overall, 23 of 62 total DSA (37%) were undetectable after treatment, 21 DSA (34%) had MFI decrease by more than 25%, and 18 (29%) had MFI decrease by less than 25% or increase. The average change in MFI was -51% ± 71% (P < .001). Despite reductions in DSA, among the six patients (32%) with biopsy-confirmed AMR, left ventricular ejection fraction (LVEF) decreased in five (83%) and cardiac index (CI) decreased in three (50%). Conversely, LVEF increased in 91% and CI increased in 70% of biopsy-negative patients. All six AMR patients were readmitted during treatment, four for confirmed or suspected rejection. IVIg infusions may stabilize the allograft in patients with elevated DSA and negative biopsies, but once AMR has developed does not appear to improve allograft function despite decreasing DSA levels.
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http://dx.doi.org/10.1111/ctr.14524DOI Listing
February 2022
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