Publications by authors named "Selim Krim"

55 Publications

Preimplant hyponatremia does not predict adverse outcomes in patient with left ventricular assist devices.

Curr Probl Cardiol 2022 May 2:101239. Epub 2022 May 2.

Division of Cardiology, John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, LA; Section of Cardiomyopathy & Heart Transplantation, John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, LA; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.

Background: Hyponatremia is a well-established marker of adverse outcomes in chronic heart failure (HF) but not well studied in patients with left ventricular assist device (LVAD).

Methods: This is a retrospective study, single center study of HM3 [Abbott, USA] LVAD implants. We divided our population based on their sodium prior to LVAD implantation - hyponatremia if <135 mEq/L and normal sodium if 135 - 145 mEq/L. We compared postoperative and long-term outcomes.

Results: A total of 195 patients were included, preimplant hyponatremia was present in 40% with a sodium of 132.1±2.1 vs. 137.8±1.9 mEq/L in the normal sodium group. No differences were observed in the postoperative or long-term outcomes.

Conclusion: Preimplant hyponatremia was not associated with mortality or HF admissions, likely due to adequate left ventricular unloading and resolution of the mechanisms that lead to hyponatremia. These results suggest that optimization of mild hyponatremia may not be critical and should not delay LVAD placement.
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http://dx.doi.org/10.1016/j.cpcardiol.2022.101239DOI Listing
May 2022

Use of plasma renin and aldosterone profiles for prognostication in acute heart failure: A step forward but not ready for prime time.

Authors:
Selim R Krim

Int J Cardiol 2022 02 30;348:111-112. Epub 2021 Nov 30.

Section of Cardiomyopathy & Heart Transplantation, Division of Cardiology, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, USA; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, USA. Electronic address:

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http://dx.doi.org/10.1016/j.ijcard.2021.11.062DOI Listing
February 2022

Reply to "The SARS-COV Pandemic Does Not Absolve From Solid Medical Trade".

Ochsner J 2021 ;21(3):238-239

Department of Cardiology, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA.

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http://dx.doi.org/10.31486/toj.21.5021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8442214PMC
January 2021

Haemodynamic-guided management of heart failure (GUIDE-HF): a randomised controlled trial.

Lancet 2021 09 27;398(10304):991-1001. Epub 2021 Aug 27.

Advocate Heart Institute, Naperville, IL, USA.

Background: Previous studies have suggested that haemodynamic-guided management using an implantable pulmonary artery pressure monitor reduces heart failure hospitalisations in patients with moderately symptomatic (New York Heart Association [NYHA] functional class III) chronic heart failure and a hospitalisation in the past year, irrespective of ejection fraction. It is unclear if these benefits extend to patients with mild (NYHA functional class II) or severe (NYHA functional class IV) symptoms of heart failure or to patients with elevated natriuretic peptides without a recent heart failure hospitalisation. This trial was designed to evaluate whether haemodynamic-guided management using remote pulmonary artery pressure monitoring could reduce heart failure events and mortality in patients with heart failure across the spectrum of symptom severity (NYHA funational class II-IV), including those with elevated natriuretic peptides but without a recent heart failure hospitalisation.

Methods: The randomised arm of the haemodynamic-GUIDEed management of Heart Failure (GUIDE-HF) trial was a multicentre, single-blind study at 118 centres in the USA and Canada. Following successful implantation of a pulmonary artery pressure monitor, patients with all ejection fractions, NYHA functional class II-IV chronic heart failure, and either a recent heart failure hospitalisation or elevated natriuretic peptides (based on a-priori thresholds) were randomly assigned (1:1) to either haemodynamic-guided heart failure management based on pulmonary artery pressure or a usual care control group. Patients were masked to their study group assignment. Investigators were aware of treatment assignment but did not have access to pulmonary artery pressure data for control patients. The primary endpoint was a composite of all-cause mortality and total heart failure events (heart failure hospitalisations and urgent heart failure hospital visits) at 12 months assessed in all randomly assigned patients. Safety was assessed in all patients. A pre-COVID-19 impact analysis for the primary and secondary outcomes was prespecified. This study is registered with ClinicalTrials.gov, NCT03387813.

Findings: Between March 15, 2018, and Dec 20, 2019, 1022 patients were enrolled, with 1000 patients implanted successfully, and follow-up was completed on Jan 8, 2021. There were 253 primary endpoint events (0·563 per patient-year) among 497 patients in the haemodynamic-guided management group (treatment group) and 289 (0·640 per patient-year) in 503 patients in the control group (hazard ratio [HR] 0·88, 95% CI 0·74-1·05; p=0·16). A prespecified COVID-19 sensitivity analysis using a time-dependent variable to compare events before COVID-19 and during the pandemic suggested a treatment interaction (p=0·11) due to a change in the primary endpoint event rate during the pandemic phase of the trial, warranting a pre-COVID-19 impact analysis. In the pre-COVID-19 impact analysis, there were 177 primary events (0·553 per patient-year) in the intervention group and 224 events (0·682 per patient-year) in the control group (HR 0·81, 95% CI 0·66-1·00; p=0·049). This difference in primary events almost disappeared during COVID-19, with a 21% decrease in the control group (0·536 per patient-year) relative to pre-COVID-19, virtually no change in the treatment group (0·597 per patient-year), and no difference between groups (HR 1·11, 95% CI 0·80-1·55; p=0·53). The cumulative incidence of heart failure events was not reduced by haemodynamic-guided management (0·85, 0·70-1·03; p=0·096) in the overall study analysis but was significantly decreased in the pre-COVID-19 impact analysis (0·76, 0·61-0·95; p=0·014). 1014 (99%) of 1022 patients had freedom from device or system-related complications.

Interpretation: Haemodynamic-guided management of heart failure did not result in a lower composite endpoint rate of mortality and total heart failure events compared with the control group in the overall study analysis. However, a pre-COVID-19 impact analysis indicated a possible benefit of haemodynamic-guided management on the primary outcome in the pre-COVID-19 period, primarily driven by a lower heart failure hospitalisation rate compared with the control group.

Funding: Abbott.
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http://dx.doi.org/10.1016/S0140-6736(21)01754-2DOI Listing
September 2021

Feasibility and Safety of Coronary Angiography via Radial Approach in Cardiac Transplant Recipients: A Single Center Experience.

Curr Probl Cardiol 2021 Jul 24:100935. Epub 2021 Jul 24.

John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA; The University of Queensland Ochsner Clinical School, Faculty of Medicine, The University of Queensland, New Orleans, LA. Electronic address:

Coronary angiography remains the gold standard post-transplant screening test for cardiac allograft vasculopathy. This procedure has traditionally been performed via femoral approach. Data on safety and efficacy of radial approach in cardiac transplant patients remains scarce. Single center retrospective study including all cardiac transplant patients who underwent coronary angiography via transradial approach (TRA) or transfemoral approach (TFA). Safety and efficacy outcomes were compared between the 2 groups. Primary end points included major bleeding, vascular complications, crossover to femoral approach, contrast use and radiation exposure. A total of 201 patients were included. 96 patients (47.8%) underwent angiography via TRA. At baseline, no significant differences with regards to age, gender, or traditional risk factors such as HTN, DM, hyperlipidemia were noted between the 2 groups. Most patients underwent intravascular ultrasound (n = 179, 89%) with no statistically significant differences between the 2 groups (TRA: 90.6% vs TFA: 87.6%, P = 0.5). Additionally, there were no statistically significant differences in radiation exposure, amount of contrast use and fluoroscopy time between the 2 groups. Although there were trends toward increased bleeding among TFA group, these were not statistically significant and were mostly driven by access site hematomas. Use of TRA increased over time and Conversion from TRA to TFA was low (n = 4, 4.2%). Coronary angiography via the radial approach in cardiac transplant recipients is feasible, safe and is associated with low a risk of bleeding with no significant increase in radiation exposure when compared to the traditional femoral approach.
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http://dx.doi.org/10.1016/j.cpcardiol.2021.100935DOI Listing
July 2021

Triple Antithrombotic Therapy in Patients With Left Ventricular Assist Devices.

Curr Probl Cardiol 2021 Jul 24:100940. Epub 2021 Jul 24.

Section of Cardiomyopathy & Heart Transplantation, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.

Data on the efficacy and safety of the combination of warfarin and dual-antiplatelet therapy compared with warfarin and mono-antiplatelet therapy (MAPT) in patients with left ventricular assist devices (LVAD) remains scarce. Single-center study of 130 consecutive patients with durable LVAD. Baseline demographics, antithrombotic and antiplatelet regimen, and outcomes were compared between patients receiving warfarin plus dual-antiplatelet therapy (Group 1) and warfarin plus MAPT (Group 2). Antiplatelet therapy was assessed at hospital discharge post-LVAD implant and included aspirin, clopidogrel and dipyridamole. Outcomes at 1-year were assessed in each group. All patients were on aspirin and warfarin. No significant differences with regards to age, gender or ethnicity were noted at baseline between the two groups. Group 1 was more likely to have higher lactate dehydrogenase LDH levels at discharge and a history of stroke. No significant differences in international normalized ratio INR, hemoglobin or hematocrit were noted at discharge. During the study period, 48 patients had gastrointestinal bleeding events: 28 of 68 (41.2%) in Group 1 vs 20 of 62 (32.2%) in Group 2 (P = 0.293). At 1year, no statistically significant differences were noted in gastrointestinal bleeding (Group 1=27.90% vs Group 2 = 25.80, P = 0.784), ischemic stroke (Group 1 = 8.8% vs group 2 = 6.5%, P = 0.612), hemorrhagic stroke (Group 1 = 4.4% vs group 2 = 3.2%, P = 0.725) or mortality (Group 1 = 5.9% vs Group 2 = 1.6%, P = 0.206). Rates of pump thrombosis however were lower in Group 1 (Group 1 = 0% vs Group 2 = 6.5%, P = 0.033). Our study showed a high prevalence of triple-therapy antithrombotic use in LVAD patients with no significant differences in bleeding, stroke or survival. However, the risk for pump thrombosis was lower at 1-year when compared to patient receiving MAPT.
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http://dx.doi.org/10.1016/j.cpcardiol.2021.100940DOI Listing
July 2021

Use of TandemHeart as Bridge to Recovery for Antibody-Mediated Rejection in a Heart Transplant Patient.

JACC Case Rep 2020 Dec 16;2(15):2358-2362. Epub 2020 Dec 16.

Section of Cardiomyopathy and Heart Transplantation, Division of Cardiology, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, The University of Queensland School of Medicine, New Orleans, Louisiana, USA.

Antibody-mediated rejection is a major cause of graft failure, mortality, and morbidity among cardiac transplant recipients. We present the first reported case of TandemHeart (LivaNova, Pittsburgh, Pennsylvania) used in the management of antibody-mediated rejection associated with cardiogenic shock. ().
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http://dx.doi.org/10.1016/j.jaccas.2020.11.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8305082PMC
December 2020

Suspected COVID-19-Induced Myopericarditis.

Ochsner J 2021 ;21(2):181-186

The University of Queensland Faculty of Medicine, Ochsner Clinical School, New Orleans, LA.

The incidence of myocarditis in patients with coronavirus disease 2019 (COVID-19) remains unknown; however, increasing evidence links COVID-19 to cardiovascular complications such as arrhythmias, heart failure, cardiogenic shock, fulminant myocarditis, and cardiac death. We present a case of suspected COVID-19-induced myopericarditis and discuss the diagnostic implications, pathophysiology, and management. A 72-year-old female was admitted to the hospital with acute on chronic respiratory failure in the setting of COVID-19. The next day, she developed pressure-like retrosternal chest pain. Laboratory findings revealed elevated cardiac enzymes and inflammatory markers consistent with myocardial injury. Electrocardiogram revealed diffuse ST segment elevations without reciprocal changes, concerning for myopericarditis. Transthoracic echocardiography showed new findings of severely reduced left ventricular (LV) systolic function, with an estimated ejection fraction (EF) of 20%. Her hospital course was further complicated by cardiogenic shock that required treatment in the intensive care unit with vasopressors and inotropes. During the next few days, she had almost full recovery of her LV function, with EF improving to 50%. However, her clinical status deteriorated, likely the result of a bowel obstruction. She was transitioned to comfort care at the request of her family, and she died shortly after. This case highlights diagnostic and therapeutic challenges that physicians may encounter when managing acute cardiac injury in the setting of COVID-19. The multiple mechanisms of COVID-19-related myocardial injury may influence the approach to diagnosis and treatment.
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http://dx.doi.org/10.31486/toj.20.0090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8238094PMC
January 2021

Rabbit Antithymocyte Globulin Induction in Heart Transplant Recipients at High Risk for Rejection.

Ochsner J 2021 ;21(2):133-138

Section of Cardiomyopathy and Heart Transplantation, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA.

Induction with lymphocyte-depleting antibodies may improve allograft outcomes in heart transplant recipients who are at high immunologic risk for rejection. We conducted a single-center retrospective cohort study that compared outcomes between adult patients receiving rabbit antithymocyte globulin (rATG) induction vs no induction from 2011 through 2017. Key exclusion criteria were patients who did not receive tacrolimus and mycophenolate and patients who did not meet high immunologic risk criteria. A total of 50 patients were included in the analysis. At 1 year, the composite primary outcome of ≥2R rejection as defined by the International Society for Heart and Lung Transplantation, any treated rejection, development of cardiac allograft vasculopathy, or graft loss was not different between groups (=0.474). Serious infections were also similar between groups (=0.963). In accordance with institutional guidelines, prednisone exposure was decreased in the rATG induction group at 1 month (24.04 mg ± 13.74 vs 35.18 mg ± 16.95; =0.014). These results suggest that while rATG induction does not improve heart allograft outcomes, it may enable reducing early corticosteroid exposure in patients at high immunologic risk.
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http://dx.doi.org/10.31486/toj.20.0024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8238107PMC
January 2021

Cardiac Amyloidosis: Presentations, Diagnostic Work-up and Collaborative Approach for Comprehensive Clinical Management.

Curr Probl Cardiol 2021 Oct 29;46(10):100910. Epub 2021 May 29.

John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, LA; Section of Cardiomyopathy & Heart Transplantation, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA. Electronic address:

Cardiac amyloidosis is a systemic disease characterized by continuous deposition of misfolded proteins called amyloid fibrils in the extracellular space which result in restrictive cardiomyopathy. The most common form of cardiac amyloidosis is light chain (AL) cardiac amyloidosis, a result of continuous deposition of misfolded monoclonal immunoglobulin light chains. Transthyretin-related cardiac amyloidosis (ATTR) results from a point mutation in the transthyretin gene in an autosomal dominant fashion and presents phenotypically similar to AL cardiac amyloidosis. Cardiac amyloidosis is being increasingly recognized due to the advancements in diagnostic cardiac imaging and pharmacotherapy. Clinicians should maintain a high index of suspicion among patients with unexplained diastolic heart failure because earlier diagnosis will allow for the implementation of disease-altering therapy. With established targeted drug therapies and further breakthroughs in immunotherapy, the potential impact of diagnostic and therapeutic advancements on morbidity and mortality of patients with cardiac amyloidosis is promising.
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http://dx.doi.org/10.1016/j.cpcardiol.2021.100910DOI Listing
October 2021

A Simplified Diagnostic and Therapeutic Approach to Pulmonary Hypertension.

Curr Probl Cardiol 2022 Apr 3;47(4):100857. Epub 2021 Apr 3.

John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, LA; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA; Section of Cardiomyopathy & Heart Transplantation, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA. Electronic address:

Pulmonary hypertension remains a common but complex disorder that physicians face in their daily practice. Pulmonary hypertension has been classified by the World Health Organization into five major categories according to etiology, pathophysiology, and hemodynamic properties. The clinical course and overall prognosis varies by etiology, therefore making the correct diagnosis is paramount to avoid delay in treatment and improve outcomes. This review aims to provide clinicians with a simplified diagnostic approach to pulmonary hypertension. We also provide a guide to risk stratification and when to refer patient to a pulmonary hypertension expert center.
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http://dx.doi.org/10.1016/j.cpcardiol.2021.100857DOI Listing
April 2022

Impact of Preinfection Left Ventricular Ejection Fraction on Outcomes in COVID-19 Infection.

Curr Probl Cardiol 2021 Oct 19;46(10):100845. Epub 2021 Mar 19.

Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, LA; Ochsner Center for Outcomes and Health Sciences Research, New Orleans, LA.

Coronavirus disease 2019 (COVID-19) has high infectivity and causes extensive morbidity and mortality. Cardiovascular disease is a risk factor for adverse outcomes in COVID-19, but baseline left ventricular ejection fraction (LVEF) in particular has not been evaluated thoroughly in this context. We analyzed patients in our state's largest health system who were diagnosed with COVID-19 between March 20 and May 15, 2020. Inclusion required an available echocardiogram within 1 year prior to diagnosis. The primary outcome was all-cause mortality. LVEF was analyzed both as a continuous variable and using a cutoff of 40%. Among 396 patients (67 ± 16 years, 191 [48%] male, 235 [59%] Black, 59 [15%] LVEF ≤40%), 289 (73%) required hospital admission, and 116 (29%) died during 85 ± 63 days of follow-up. Echocardiograms, performed a median of 57 (IQR 11-122) days prior to COVID-19 diagnosis, showed a similar distribution of LVEF between survivors and decedents (P = 0.84). Receiver operator characteristic analysis revealed no predictive ability of LVEF for mortality, and there was no difference in survival among those with LVEF ≤40% versus >40% (P = 0.49). Multivariable analysis did not change these relationships. Similarly, there was no difference in LVEF based on whether the patient required hospital admission (56 ± 13 vs 55 ± 13, P = 0.38), and patients with a depressed LVEF did not require admission more frequently than their preserved-LVEF peers (P = 0.87). A premorbid history of dyspnea consistent with symptomatic heart failure was not associated with mortality (P = 0.74). Among patients diagnosed with COVID-19, pre-COVID-19 LVEF was not a risk factor for death or hospitalization.
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http://dx.doi.org/10.1016/j.cpcardiol.2021.100845DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7972833PMC
October 2021

Ruptured hemorrhagic bulla in a patient with a HeartMate 3 treated with an Amplatzer device.

Arch Cardiol Mex 2021 Mar 24. Epub 2021 Mar 24.

Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, LA, USA; Ochsner Clinical School, Faculty of Medicine, The University of Queensland, New Orleans, LA, USA.

A 60-year-old female with underlying emphysema and left ventricular assist device (LVAD) HeartMate 3 presented with progressive hemoptysis, dyspnea, and right chest pain. Baseline hemoglobin was 11.1 g/dL and INR 2.9.
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http://dx.doi.org/10.24875/ACM.20000331DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8351646PMC
March 2021

PET Stress Testing with Coronary Flow Capacity in the Evaluation of Patients with Coronary Artery Disease and Left Ventricular Dysfunction: Rethinking the Current Paradigm.

Curr Cardiol Rep 2021 03 24;23(4):50. Epub 2021 Mar 24.

Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, 1514 Jefferson Highway, New Orleans, LA, 70121-2483, USA.

Purpose Of Review: Cardiomyopathy with underlying left ventricular (LV) dysfunction is a heterogenous group of disorders that may be present with, and/or secondary to, coronary artery disease (CAD). The purpose of this review is to demonstrate, via case illustrations, the benefits offered by cardiac positron-emission tomography (PET) stress testing with coronary flow capacity (CFC) in the evaluation and treatment of patients with left ventricular (LV) dysfunction and CAD.

Recent Findings: CFC, a metric that is increasing in prominence, represents the integration of several absolute perfusion metrics into clinical strata of CAD severity. Our prior work has demonstrated improvement in regional perfusion metrics as a result of revascularization to territories with severe reduction in CFC. Conversely, when CFC is adequate, there is no change in regional perfusion metrics following revascularization, despite angiographically severe stenosis. Furthermore, Gould et al. demonstrated decreased rates of myocardial infarction and death following revascularization of myocardium with severely reduced CFC, with no clinical benefit observed following revascularization of patients with preserved CFC. In a series of cases, we present pre-revascularization and post-revascularization PET scans with perfusion metrics in patients with LV dysfunction and CAD. In these examples, we demonstrate improvement in LV function and perfusion metrics following revascularization only in cases where baseline CFC is severely reduced. PET with CFC offers unique guidance regarding revascularization in patients with reduced LV function and CAD.
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http://dx.doi.org/10.1007/s11886-021-01478-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7990801PMC
March 2021

Leadless and Wireless Cardiac Devices: The Next Frontier in Remote Patient Monitoring.

Curr Probl Cardiol 2021 May 24;46(5):100800. Epub 2021 Jan 24.

John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, LA; Section of Cardiomyopathy & Heart Transplantation, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA. Electronic address:

In the last decade, advances in wireless and sensor technologies, and the implementation of telemedicine, have led to innovative digital health care for cardiac patients. Continuous monitoring of patients' biomedical signals, and acute changes in these signals, may result in timely, accurate diagnoses and implementation of early interventions. In this review, we discuss commonly used wireless and leadless cardiac devices including pulmonary artery pressure sensors, implantable loop recorders, leadless pacemakers and subcutaneous implantable cardioverter-defibrillators. We discuss the concept and function of each device, indications, methods of delivery, potential complications, consideration for implantation, and cost-effectiveness.
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http://dx.doi.org/10.1016/j.cpcardiol.2021.100800DOI Listing
May 2021

Laparoscopic sleeve gastrectomy in obese patients with ventricular assist devices: a data note.

BMC Res Notes 2020 Sep 17;13(1):439. Epub 2020 Sep 17.

The John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA, USA.

Objectives: Patients with end-stage heart failure (ESHF) treated with ventricular assist devices (VADs) tend to gain weight after implantation, which is associated with higher complication rates and is a contraindication for heart transplantation (HT). The objective was to analyze the outcomes of obese patients with ESHF and VADs who underwent laparoscopic sleeve gastrectomy (LSG) at Ochsner Medical Center in New Orleans, which is the only program performing VADs and HT in the State of Louisiana, and also one of the largest VAD centers in the USA.

Data Description: This dataset contains detailed baseline, perioperative, and long-term data of patients with VADs undergoing LSG. These variables were collected retrospectively from electronic medical records. Patients who achieved ≥ 50% excess BMI loss, BMI ≤ 35 kg/m, listing for HT, HT, or myocardial recovery were identified and the timing to each of these milestones was documented. These data can be used alone or in combination with other datasets to achieve a larger sample size with more power for further analysis of these variables, which include the most important, standard, and objective bariatric and ESHF outcomes of patients with VADs undergoing LSG. Elaboration of composite outcomes is feasible.
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http://dx.doi.org/10.1186/s13104-020-05272-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7496210PMC
September 2020

Laparoscopic Sleeve Gastrectomy in Patients with Obesity and Ventricular Assist Devices: a Comprehensive Outcome Analysis.

Obes Surg 2021 02 25;31(2):884-890. Epub 2020 Aug 25.

John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA, USA.

We analyzed in detail the outcomes of eight patients with ventricular assist devices (VADs) and obesity who underwent laparoscopic sleeve gastrectomy (LSG) at a single heart transplant (HT) center. This comprehensive analysis included body mass index (BMI) trends from VAD implantation to the time of LSG; BMI and percentage of excess BMI lost during follow-up; adverse outcomes; and changes in echocardiographic parameters, fasting lipids, unplanned hospitalizations, and functional status. We also identified the patients who achieved the following outcomes: listing for HT, HT, 50% excess BMI loss, and BMI < 35 kg/m. Laparoscopic sleeve gastrectomy seems to be a reasonable and effective intervention to help patients with VADs and obesity to decrease excess BMI and become candidates for HT.
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http://dx.doi.org/10.1007/s11695-020-04948-9DOI Listing
February 2021

Hypertension in cardiac transplant recipients: tackling a new face of an old foe.

Curr Opin Cardiol 2020 07;35(4):368-375

Division of Cardiology, John Ochsner Heart and Vascular Institute.

Purpose Of Review: Systemic hypertension (HTN) is a common complication arising in the heart transplant recipient. This article aims to review the most current literature and update readers on the epidemiology, pathophysiology and management of HTN in heart transplant patients.

Recent Findings: In contrast to the general nontransplant hypertensive patient population, traditional risk factors, including family history of HTN, obesity and diabetes, play a minor role in the genesis of posttransplant HTN. Dysregulation in sodium and water balance, vascular stiffness, endothelial dysfunction, abnormal cardiorenal neural reflexes resulting from immunosuppression and cardiac denervation seem to be the predominant factors leading to postheart transplant HTN. Calcineurin inhibitors induced nephrotoxicity and steroid use further contributes to posttransplant HTN.

Summary: Owing to the paucity of data, particularly randomized controlled trials to guide the evaluation and management of HTN in the cardiac transplant patients, much of the available data come from the renal transplant population. The choice of antihypertensive should be based on timing related to transplantation and patient's comorbidities. Although calcium channel blockers and loop diuretics are the preferred agents in the early postheart transplant period, angiotensin-converting-enzyme inhibitors and angiotensin receptor blockers may be beneficial in the late postheart transplant period especially in the setting of diabetes and in the presence of proteinuria.
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http://dx.doi.org/10.1097/HCO.0000000000000743DOI Listing
July 2020

Cardiac Transplantation: Update on a Road Less Traveled.

Ochsner J 2019 ;19(4):369-377

Department of Cardiology, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA.

With an aging population, the prevalence of heart failure continues to rise. The use of guideline-directed medical therapy and mechanical circulatory support devices has helped to improve outcomes, but cardiac transplantation remains the definitive treatment for end-stage heart failure. We provide an update on cardiac transplantation and review indications, contraindications, and important aspects of perioperative and postoperative management. We also highlight the current challenges faced by the transplant community. Advances in surgical techniques and immunosuppression have increased survival rates posttransplant. However, the risk of rejection and adverse effects from chronic immunosuppression continue to affect long-term outcomes. Despite tremendous progress in the management of cardiac transplant patients, we have much opportunity to further optimize cardiac transplant waitlisting and improve posttransplant outcomes.
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http://dx.doi.org/10.31486/toj.19.0022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6928671PMC
January 2019

Managing hypertension in patients with heart failure: an ongoing quandary.

Curr Opin Cardiol 2019 07;34(4):359-366

Division of Cardiology, John Ochsner Heart and Vascular Institute.

Purpose Of Review: Hypertension (HTN) is one of the strongest risk factors for heart failure and is prevalent in up to 91% of patients with newly diagnosed heart failure. This article offers a practical approach to HTN in patients with heart failure.

Recent Findings: To date, no randomized trials comparing specific antihypertensive regimens have been conducted in the heart failure population. Management of heart failure with reduced ejection fraction patients with elevated blood pressure (BP) should include guideline-directed medical therapy [angiotensin-converting-enzyme inhibitors (ACEis), aldosterone receptor blockers, AT1 neprilysin-inhibitors, beta blockers and aldosterone blockers] titrated to maximal tolerated doses regardless of BP. Despite the lack of survival benefit current available data suggest the use of ACEis, aldosterone receptor blockers as first-line therapy for HTN in patients with heart failure with preserved ejection fraction.

Summary: Management of HTN in heart failure patients should be based on left ventricular function. Recent findings suggest that AT1 neprilysin-inhibitors offer better BP control when compared with ACEi, or aldosterone receptor blockers and therefore should be used as first-line therapy in hypertensive patients with heart failure with reduced ejection fraction. Their role as antihypertensive agents in heart failure with preserved ejection fraction seems promising but remains under investigation.
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http://dx.doi.org/10.1097/HCO.0000000000000634DOI Listing
July 2019

Left ventricular assist devices in the treatment of advanced heart failure.

JAAPA 2019 May;32(5):41-46

At the Ochsner Clinic Foundation in New Orleans, La., Miriam Becnel practices in the Section of Cardiomyopathy and Heart Transplantation in the John Ochsner Heart and Vascular Institute and Selim R. Krim is director of the Heart Failure Clinical Research Section of Cardiomyopathy and Heart Transplantation. The authors have disclosed no potential conflicts of interest, financial or otherwise.

The left ventricular assist device (LVAD) is becoming the standard of care in treating patients with advanced heart failure. This article describes available LVADs, their clinical indications, and important caveats when caring for this complex patient population.
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http://dx.doi.org/10.1097/01.JAA.0000554741.01311.bbDOI Listing
May 2019

Editorial commentary: Acute heart failure: A patient's curse or a provider's opportunity?

Authors:
Selim R Krim

Trends Cardiovasc Med 2020 02 16;30(2):113-114. Epub 2019 Apr 16.

Division of Cardiology, John Ochsner Heart and Vascular Institute, United States; Section of Cardiomyopathy and Heart Transplantation, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, United States; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA, United States. Electronic address:

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http://dx.doi.org/10.1016/j.tcm.2019.04.004DOI Listing
February 2020

A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).

J Card Fail 2018 Oct 7;24(10):661-671. Epub 2018 Sep 7.

Houston Methodist Hospital, Houston, Texas.

Background: Studies indicate that decision making and informed consent among patients considering left ventricular assist device (LVAD) support for advanced heart failure could be improved. In the VADDA (Ventricular Assist Device Decision Aid) trial, we tested a patient-centered decision aid (DA) to enhance the quality of decision making about LVAD therapy.

Methods: After an extensive user-centered design process, we conducted a multisite randomized trial of the DA compared with standard education (SE) among inpatients considering LVAD treatment for advanced heart failure The main outcome was LVAD knowledge at 1 week and 1 month after administration of the DA versus the SE, according to a validated scale. Secondary measures included prespecified quality decision making measures recommended by the International Patient Decision Aid Standards collaboration.

Results: Of 105 eligible patients, 98 consented and were randomly assigned to the DA and SE arms. Patients receiving the VADDA exhibited significantly greater LVAD knowledge than the SE group at 1 week of follow-up (P = .01) but not at 1 month (P = .47). No differences were found between DA and SE patients in rates of acceptance versus decline of LVAD treatment (85% vs 78%; P = .74). Recipients in the DA arm reported greater satisfaction with life after implantation compared with nonrecipients (28 vs 23 out of 30; P = .008), although both arms reported high satisfaction. Patients rated the DA high in acceptability and usability.

Conclusions: The VADDA enhances LVAD knowledge, particularly in the short term (1 week) during the peak period of decision making. The DA does not encourage decision direction and reflects patient, caregiver, and physician preferences for content and format.

Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT02248974. The trial is registered with clinicaltrials.gov (NCT02248974).
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http://dx.doi.org/10.1016/j.cardfail.2018.08.008DOI Listing
October 2018

Pharmacologic Therapy for Heart Failure With Reduced Ejection Fraction: Closing the Gap Between Clinical Guidelines and Practice.

Prog Cardiovasc Dis 2017 Sep - Oct;60(2):187-197. Epub 2017 Aug 25.

Division of Cardiology, John Ochsner Heart and Vascular Institute, New Orleans, LA, United States; Section of Cardiomyopathy & Heart Transplantation, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA, United States; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA, United States. Electronic address:

Despite the great progress made in the management of heart failure (HF) with reduced ejection fraction (HFrEF), its prevalence continues to rise owing to an aging population and an epidemic of hypertension, obesity and coronary artery disease. For decades, angiotensin converting enzyme inhibitors and beta blockers have been the mainstay of HFrEF therapy. The recent addition of sacubitril/valsartan and ivabradine to the HF armamentarium has the potential to transform our therapeutic approach to HFrEF, while simultaneously raising some questions and uncertainties on their applicability. In this paper, we review the pathophysiology of HFrEF, discuss already established and novel evidenced-based pharmacologic therapies available for these patients. We also share some therapeutic strategies aimed to optimize HF therapy in specific undertreated patient populations including the elderly and patients with chronic kidney disease, while offering insight on how to tailor therapy in the "real-world."
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http://dx.doi.org/10.1016/j.pcad.2017.08.006DOI Listing
October 2017

Changing our Approach to Stage D Heart Failure.

Prog Cardiovasc Dis 2017 Sep - Oct;60(2):205-214. Epub 2017 Aug 9.

Division of Cardiology, John Ochsner Heart and Vascular Institute, New Orleans, LA, United States; Section of Cardiomyopathy & Heart Transplantation, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121, United States; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA, United States. Electronic address:

Despite the tremendous progress made in the management of heart failure (HF), many patients reach advanced stages. This paper aims to present a practical approach to the stage D HF patient who is no longer responding to optimal medical therapy. We discuss all available therapies for this patient population. We also offer some important caveats with regard to identification, risk stratification, evaluation and treatment including early patient referral to a center with an advanced HF program. Given the changing landscape of heart transplantation and an impending change in the allocation system, we also intend to engage a discussion on the need for a paradigm shift towards left ventricular assist device therapy in this population.
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http://dx.doi.org/10.1016/j.pcad.2017.08.003DOI Listing
October 2017

Hypertensive crisis: an update on clinical approach and management.

Curr Opin Cardiol 2017 Jul;32(4):397-406

aDepartment of Cardiology, Erzurum Training and Research Hospital, Erzurum, Turkey bDepartment of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute cOchsner Clinical School - The University of Queensland School of Medicine, New Orleans, Louisiana, USA.

Purpose Of Review: Here, we review current concepts on hypertensive crisis (HTN-C) with a focus on epidemiology, causes, pathophysiology and prognosis. We also offer a practical approach to the management of HTN-C.

Recent Findings: HTN-C is characterized by a severe and abrupt increase in blood pressure (BP) with impending or progressive acute end-organ damage (EOD). HTN-C can be divided into hypertensive emergency (HTN-E) and hypertensive urgency (HTN-U) based on the presence or absence of acute EOD, respectively. Recent retrospective studies have demonstrated that emergency department (ED) referrals from an outpatient clinic or rapid BP-lowering strategies in the ED do not lead to improved outcomes in patients with HTN-U.

Summary: HTN-C can be a de-novo manifestation or a complication of essential or secondary HTN. The presence of acute EOD is a major poor prognostic indicator in HTN-C. The main objectives of the management of HTN-C are distinction of HTN-E from HTN-U and appropriate risk stratification, prevention or regression of acute EOD due to severely elevated BP, prevention of recurrence of HTN-C with an effective long-term management plan and avoidance of rapid lowering of BP except in some special circumstances. The majority of patients with asymptomatic HTN-U can be safely managed in the outpatient setting without exposing them to the risks of aggressive BP lowering. However, patients with HTN-E require hospitalization, prompt treatment and close monitoring.
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http://dx.doi.org/10.1097/HCO.0000000000000398DOI Listing
July 2017

Mechanical Circulatory Support for the Failing Heart: Continuous-Flow Left Ventricular Assist Devices.

Ochsner J 2016 ;16(3):263-9

Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA ; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.

Background: Heart transplantation remains the definitive therapy for patients with advanced heart failure; however, owing to limited donor organ availability and long wait times, continuous-flow left ventricular assist devices (LVADs) have become standard therapy.

Methods: This review summarizes the history, progression, function, and basic management of LVADs. Additionally, we provide some clinical pearls and important caveats for managing this unique patient population.

Results: Currently, the most common LVADs being implanted in the United States are second- and third-generation devices, the HeartMate II (Thoratec Corp., St. Jude Medical) and the HeartWare HVAD (HeartWare International, Inc.). A newer third-generation pump, the HeartMate III (Thoratec Corp., St. Jude Medical), is designed to create an artificial pulse and is currently under investigation in the United States.

Conclusion: LVAD use is promising, will continue to grow, and has become standard therapy for advanced heart failure as a bridge to recovery, as destination therapy, and as a bridge to transplantation.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5024808PMC
September 2016

Percutaneous Ventricular Assist Devices: A Novel Approach in the Management of Patients With Acute Cardiogenic Shock.

Ochsner J 2016 ;16(3):243-9

Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA ; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.

Background: Despite recent advances in the management of heart failure, cardiogenic shock remains a challenging and devastating condition with significant morbidity and mortality.

Methods: We review currently available percutaneous mechanical circulatory support (MCS) devices and address each device's characteristics, mechanism of action, specific clinical indications, and contraindications.

Results: Four types of percutaneous MCS devices are currently available: the intraaortic balloon pump (IABP), Impella devices, the TandemHeart, and extracorporal membrane oxygenation (ECMO). IABPs provide less hemodynamic support compared to the Impella, TandemHeart, and ECMO devices. However, because of its ease of placement and relatively small access catheter size, the IABP remains the most commonly used MCS device for the treatment of cardiogenic shock. When full cardiopulmonary support is needed, ECMO is the best option.

Conclusion: Temporary MCS has emerged as a therapeutic option in the management of patients with acute cardiogenic shock. However, clinician familiarity with the indications, limitations, and benefits of individual MCS devices and enhanced patient comfort with the placement are paramount to improve patient outcomes.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5024805PMC
September 2016

Hypertension and ethnicity.

Curr Opin Cardiol 2016 07;31(4):381-6

aDepartment of Medicine bDivision of Cardiology, John Ochsner Heart and Vascular Center, Ochsner Medical Center cThe University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana, USA.

Purpose Of Review: Despite its continued increase in prevalence in minorities, data regarding hypertension (HTN) control among such ethnic groups remains limited. This review highlights the most recent literature on the epidemiology, prevalence, and treatment strategies of HTN among four racial groups (non-Hispanic Whites (NHW), Blacks, Hispanics, and Asians).

Recent Findings: Overall awareness and treatment of HTN were found to be higher in blacks when compared with NHWs. Access to health insurance is associated with successful HTN control, particularly among the Hispanic populations. Recent data from SBP Intervention Trial suggests the blood pressure control and adherence rates in blacks were highest among men, with a higher number of comorbidities, and on diuretic therapy. Additionally, the initiation of thiazide-type diuretics and calcium channel blocker was superior to β-adrenergic blockers and angiotensin converting enzyme inhibitor/angiotensin receptor blockers in blood pressure lowering among blacks. However, no specific treatment recommendations exist for Hispanics or Asians. Finally, recent guidelines from the Joint National Commission recommend initial treatment with a thiazide-type diuretic regardless of race.

Summary: Despite recent progress, racial disparities in awareness and treatment of HTN continue to exist. To reduce this important gap, future research should focus on epidemiologic, genetic, and sociologic factors as well as specific therapies to achieve maximum medical benefit in these subgroups.
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http://dx.doi.org/10.1097/HCO.0000000000000293DOI Listing
July 2016
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