Publications by authors named "Veli K Topkara"

144 Publications

ECMO as a Bridge to Left Ventricular Assist Device or Heart Transplantation.

JACC Heart Fail 2021 Apr 10;9(4):281-289. Epub 2021 Mar 10.

Milstein Division of Cardiology, Department of Medicine, New York Presbyterian - Columbia University Irving Medical Center, New York, New York, USA. Electronic address:

Objectives: The purpose of this study was to compare outcomes between patients on extracorporeal membrane oxygenation (ECMO) bridged to left ventricular assist device (LVAD) versus heart transplantation (HT) using registry data.

Background: Patients with heart failure supported with ECMO represent the highest priority in the new HT allocation system. For patients on ECMO, bridging to LVAD may be non-inferior compared with bridging to HT.

Methods: Adult patients in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) from 2006 to 2017 and United Network for Organ Sharing (UNOS) database from 2006 to June 2019 requiring ECMO were included. Cause-specific hazard models were created and cumulative incidence functions were calculated with mortality, transplantation, and re-transplantation as competing events.

Results: A total of 906 patients received ECMO as bridge to VAD (n = 587, 64.8%) or as bridge to HT (n = 319, 35.2%). Patients bridged directly to HT were younger (age 46.3 ± 15.4 years vs. 52.1 ± 13.2 years; p < 0.001) and more likely to be female (93 [29.2%] vs. 139 [23.7%]; p = 0.022). Patients bridged directly to HT were more likely to have a nonischemic cardiomyopathy, restrictive physiologies, and allograft failure; (p < 0.05 for all). ECMO use increased over time in both UNOS and INTERMACS. There was no significant difference in mortality between groups (Gray's p = 0.581). This remained true even when the analysis was restricted to transplant-listed or eligible patients as well as patients with dilated phenotypes (excluding patients with congenital heart disease, restrictive phenotypes, and allograft failure).

Conclusions: There was no difference in mortality on pump support compared with posttransplant mortality among those bridged from ECMO to LVAD or HT.
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http://dx.doi.org/10.1016/j.jchf.2020.12.012DOI Listing
April 2021

Increased Aortic Stiffness Is Associated With Higher Rates of Stroke, Gastrointestinal Bleeding and Pump Thrombosis in Patients With a Continuous Flow Left Ventricular Assist Device.

J Card Fail 2021 Feb 24. Epub 2021 Feb 24.

Columbia University Irving Medical Center, New York, New York; Cardiff School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, UK. Electronic address:

Background: In the general population, increased aortic stiffness is associated with an increased risk of cardiovascular events. Previous studies have demonstrated an increase in aortic stiffness in patients with a continuous flow left ventricular assist device (CF-LVAD). However, the association between aortic stiffness and common adverse events is unknown.

Methods And Results: Forty patients with a HeartMate II (HMII) (51 $ 11 years; 20% female; 25% ischemic) implanted between January 2011 and September 2017 were included. Two-dimensional transthoracic echocardiograms of the ascending aorta, obtained before HMII placement and early after heart transplant, were analyzed to calculate the aortic stiffness index (AO-SI). The study cohort was divided into patients who had an increased vs decreased AO-SI after LVAD support. A composite outcome of gastrointestinal bleeding, stroke, and pump thrombosis was defined as the primary end point and compared between the groups. While median AO-SI increased significantly after HMII support (AO-SI 4.4-6.5, P = .012), 16 patients had a lower AO-SI. Patients with increased (n = 24) AO-SI had a significantly higher rate of the composite end point (58% vs 12%, odds ratio 9.8, P < .01). Similarly, those with increased AO-SI tended to be on LVAD support for a longer duration, had higher LVAD speed and reduced use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers.

Conclusions: Increased aortic stiffness in patients with a HMII is associated with a significantly higher rates of adverse events. Further studies are warranted to determine the causality between aortic stiffness and adverse events, as well as the effect of neurohormonal modulation on the conduit vasculature in patients with a CF-LVAD.
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http://dx.doi.org/10.1016/j.cardfail.2021.02.009DOI Listing
February 2021

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

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

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

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

C-Reactive Protein Levels Predict Outcomes in Continuous-Flow Left Ventricular Assist Device Patients: An INTERMACS Analysis.

ASAIO J 2021 Jan 28. Epub 2021 Jan 28.

From the Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina Division of Cardiothoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

CRP is an established inflammatory biomarker with prognostic value in patients with chronic heart failure, yet its role in continuous-flow left ventricular assist device (LVAD) patients is largely unknown. 5,183 patients from the INTERMACS registry who underwent durable LVAD between 2008 and 2017 and had preimplant CRP levels were included. The sample was stratified into two groups based on preimplant CRP levels: CRP of 0-10 mg/L (low) and >10 mg/L (high). Kaplan-Meier survival estimates were used to assess outcomes at 2 years after LVAD implantation, with log-rank testing used to compare groups. Cox proportional hazard models were used for multivariable adjustment. Patients with high preimplant CRP were younger, more likely to be INTERMACS class I, and had a higher need for temporary mechanical circulatory support before LVAD implant compared to those with lower CRP levels (all P < 0.001). The high CRP group had higher WBC counts and BNP levels (all P < 0.001). After adjustment, higher CRP (>10 mg/L) was associated with greater risk of mortality, RV failure, and stroke postimplant (P < 0.001). In addition, elevated postimplant CRP level at 3 months was associated with increased mortality and stroke on LVAD support (P < 0.001). CRP is a predictor of death and complications on LVAD support. Future studies are necessary to explore the mechanisms underlying this finding and the potential role of antiinflammatory therapies in this population.
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http://dx.doi.org/10.1097/MAT.0000000000001327DOI Listing
January 2021

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

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

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

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

Impella percutaneous left ventricular assist device as mechanical circulatory support for cardiogenic shock: A retrospective analysis from a tertiary academic medical center.

Catheter Cardiovasc Interv 2020 Dec 16. Epub 2020 Dec 16.

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

Objectives: To describe hemodynamic efficacy and clinical outcomes of Impella percutaneous left ventricular assist device (pLVAD) in patients with cardiogenic shock (CS).

Background: Percutaneous LVADs are increasingly used in CS management. However, device-related outcomes and optimal utilization remain active areas of investigation.

Methods: All CS patients receiving pLVAD as mechanical circulatory support (MCS) between 2011 and 2017 were identified. Clinical characteristics and outcomes were analyzed. A multivariable logistic regression model was created to predict MCS escalation despite pLVAD. Outcomes were compared between early and late implantation.

Results: A total of 115 CS patients (mean age 63.6 ± 13.8 years; 69.6% male) receiving pLVAD as MCS were identified, the majority with CS secondary to acute myocardial infarction (AMI; 67.0%). Patients experienced significant cardiac output improvement (median 3.39 L/min to 3.90 L/min, p = .002) and pharmacological support reduction (median vasoactive-inotropic score [VIS] 25.4 to 16.4, p = .049). Placement of extracorporeal membrane oxygenation (ECMO) occurred in 48 (41.7%) of patients. Higher pre-pLVAD VIS was associated with subsequent MCS escalation in the entire cohort and AMI subgroup (OR 1.27 [95% CI 1.02-1.58], p = .034 and OR 1.72 [95% CI 1.04-2.86], p = .035, respectively). Complications were predominantly access site related (bleeding [9.6%], vascular injury [5.2%], and limb ischemia [2.6%]). In-hospital mortality was 57.4%, numerically greater survival was noted with earlier device implantation.

Conclusions: Treatment with pLVAD for CS improved hemodynamic status but did not uniformly obviate MCS escalation. Mortality in CS remains high, though earlier device placement for appropriately selected patients may be beneficial.
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http://dx.doi.org/10.1002/ccd.29434DOI Listing
December 2020

Comparing outcomes for infiltrative and restrictive cardiomyopathies under the new heart transplant allocation system.

Clin Transplant 2020 12 28;34(12):e14109. Epub 2020 Oct 28.

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

The new heart transplantation (HT) allocation policy was introduced on 10/18/2018. Using the UNOS registry, we examined early outcomes following HT for restrictive cardiomyopathy, hypertrophic cardiomyopathy, cardiac sarcoidosis, or cardiac amyloidosis compared to the old system. Those listed who had an event (transplant, death, or waitlist removal) prior to 10/17/2018 were in Era 1, and those listed on or after 10/18/2018 were in Era 2. The primary endpoint was death on the waitlist or delisting due to clinical deterioration. A total of 1232 HT candidates were included, 855 (69.4%) in Era 1 and 377 (30.6%) in Era 2. In Era 2, there was a significant increase in the use of temporary mechanical circulatory support and a reduction in the primary endpoint, (20.9 events per 100 PY (Era 1) vs. 18.6 events per 100 PY (Era 2), OR 1.98, p = .005). Median waitlist time decreased (91 vs. 58 days, p < .001), and transplantation rate increased (119.0 to 204.7 transplants/100 PY for Era 1 vs Era 2). Under the new policy, there has been a decrease in waitlist time and waitlist mortality/delisting due to clinical deterioration, and an increase in transplantation rates for patients with infiltrative, hypertrophic, and restrictive cardiomyopathies without any effect on post-transplant 6-month survival.
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http://dx.doi.org/10.1111/ctr.14109DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7755228PMC
December 2020

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

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

Division of Cardiothoracic Surgery. Electronic address:

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

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

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

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

Trends in US Heart Transplant Waitlist Activity and Volume During the Coronavirus Disease 2019 (COVID-19) Pandemic.

JAMA Cardiol 2020 Sep;5(9):1048-1052

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

Importance: Solid organ transplants have declined significantly during the coronavirus disease (COVID-19) pandemic in the US. Limited data exist regarding changes in heart transplant (HT).

Objective: To describe national and regional trends in waitlist inactivations, waitlist additions, donor recovery, and HT volume during COVID-19.

Design, Setting, And Participants: This descriptive cross-sectional study used publicly available data from the United Network for Organ Sharing and US Centers for Disease Control and Prevention, using 8 prespecified United Network for Organ Sharing regions. Adult (18 years or older) HT candidates listed and deceased donors recovered between January 19 to May 9, 2020.

Exposures: COVID-19 pandemic.

Main Outcomes And Measures: Changes in waitlist inactivations, waitlist additions, deceased donor recovery, and transplant volumes from the pre-COVID-19 (January 19-March 15, 2020) to the COVID-19 era (March 15-May 9, 2020). Density mapping and linear regression with interrupted time series analysis were used to characterize changes over time and changes by region.

Results: During the COVID-19 era, there were 600 waitlist inactivations compared with 343 during the pre-COVID era (75% increase). Waitlist additions decreased from 637 to 395 (37% reduction). These changes were most profound in the Northeast and Great Lakes regions with high rates of COVID-19. Deceased donor recovery decreased by 26% from 1878 to 1395; the most significant decrease occurred in the North Midwest despite low COVID-19 prevalence. Heart transplant volumes were significantly reduced across all regions except the Northwest. The largest decrease was seen in the Northeast where COVID-19 case rates were highest. From the pre-COVID-19 era to the COVID-19 era, there was significant regional variation in waitlist additions (eg, 69% decrease in the Northeast vs 8.5% increase in the South Midwest; P < .001) and deceased donor recovery (eg, 41% decrease in North Midwest vs 16% decrease in South Midwest; P = .02).

Conclusions And Relevance: Heart transplant volumes have been significantly reduced in recent months, even in regions with a lower prevalence of COVID-19 cases. This has been accompanied by increased waitlist inactivations, decreased waitlist additions, and decreased donor recovery. Future studies are needed to determine if the COVID-19 pandemic is associated with changes in waitlist mortality.
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http://dx.doi.org/10.1001/jamacardio.2020.2696DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376479PMC
September 2020

Psychosocial Risk and Its Association With Outcomes in Continuous-Flow Left Ventricular Assist Device Patients.

Circ Heart Fail 2020 09 8;13(9):e006910. Epub 2020 Sep 8.

Division of Cardiology, Department of Medicine (E.M. DeFilippis, E.M. Donald, G.S., P.C.C., M.Y., N.U., M.A.F., V.K.T.), Columbia University College of Physicians and Surgeons, New York, NY.

Background: Advanced heart failure therapies such as left ventricular assist device (LVAD) implantation require intricate follow-up and complex care. We sought to explore the burden of psychosocial risk factors among patients with LVAD and their impact on postimplant outcomes using the Interagency Registry for Mechanically Assisted Circulatory Support.

Methods: Adult patients in the Interagency Registry for Mechanically Assisted Circulatory Support requiring durable LVAD between 2008 and 2017 were included. Individuals were determined to have psychosocial risk if they had one of the following: (1) limited social support; (2) limited cognition; (3) substance abuse (alcohol and drug); (4) severe psychiatric disease (including major depression and other major psychiatric diagnosis); and (5) repeated noncompliance. Univariate and multivariate Cox proportional hazard regression models were used to analyze predictors of survival and complications.

Results: A total of 15 403 continuous-flow LVAD recipients were included. A total of 3163 (20.5%) had one or more psychosocial risk factors. The most prevalent psychosocial risk factor was substance abuse in 1941 (12.6%) recipients. Patients with psychosocial risk factors were significantly younger at LVAD implant, less likely to be White, and less likely to be female compared with those without psychosocial risk, <0.001 for all. Patients with psychosocial risk were significantly more likely to receive an LVAD as destination therapy, <0.001. In adjusted models, patients with psychosocial risk were at increased hazards for device-related infection, gastrointestinal bleeding, pump thrombosis, and readmission and reduced hazards for cardiac transplantation (<0.05 for all). There was no statistically significant difference in survival on pump support or stroke.

Conclusions: Psychosocial risk is an important component of patient selection for advanced heart failure therapies. Addressing these specific components may help improve access to advanced therapies and post-LVAD outcomes.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.120.006910DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527209PMC
September 2020

Cardiac Implantable Electronic Devices Following Heart Transplantation.

JACC Clin Electrophysiol 2020 08;6(8):1028-1042

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

Permanent pacemaker (PPM) implantation is required in a subset of patients (∼10%) for sinus node dysfunction or atrioventricular block both early and late after heart transplantation. The incidence of PPM implantation has decreased to <5% with the advent of bicaval anastamosis transplantation surgery. Pacing dependence upon follow-up has been variably reported. An even smaller percentage of transplantation recipients (1.5% to 3.4%) undergo implantable cardioverter-defibrillator (ICD) placement. Rigorous data are lacking for the use of ICDs in the transplantation population and is largely derived from cohort studies and case series. Sudden cardiac death occurs in approximately 10% of transplantation recipients, but multiple nonarrhythmic factors are believed to be responsible, including acute rejection, late graft failure with electromechanical dissociation, and ischemia due to cardiac allograft vasculopathy. This review provides a comprehensive analysis of the existing data regarding the role for PPMs and ICDs in this population, including leadless PPMs and subcutaneous ICDs, special considerations, and future directions.
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http://dx.doi.org/10.1016/j.jacep.2020.06.023DOI Listing
August 2020

Gut microbial diversity, inflammation, and oxidative stress are associated with tacrolimus dosing requirements early after heart transplantation.

PLoS One 2020 29;15(5):e0233646. Epub 2020 May 29.

Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital, Columbia University, New York, New York, United States of America.

Introduction: Effective tacrolimus (TAC) dosing is hampered by complex pharmacokinetics and significant patient variability. The gut microbiome, a key mediator of endotoxemia, inflammation and oxidative stress in advanced heart failure (HF) patients, is a possible contributor to interindividual variations in drug efficacy. The effect of alterations in the gut microbiome on TAC dosing requirements after heart transplant (HT) has not been explored.

Methods: We enrolled 24 patients (mean age = 55.8 ±2.3 years) within 3 months post-HT. Biomarkers of endotoxemia ((lipopolysaccharide (LPS)), inflammation (tumor necrosis factor-α (TNF-α)) and oxidative stress (8,12-iso-Isoprostane F-2alpha-VI) were measured in 16 blood samples. 22 stool samples were analyzed using 16S rRNA sequencing. TAC dose and serum trough level were measured at the time of stool and blood collection. TAC doses were reported in mg/kg/day and as level-to-dose (L/D) ratio, and categorized as ≤ vs. > median.

Results: The median TAC dose was 0.1 mg/kg/day and L/D ratio was 100.01. Above the median daily weight-based TAC dose was associated with higher gut microbial alpha diversity (p = 0.03); similarly, TNF-α and 8,12-iso-Isoprostane F-2alpha-VI levels were lower and LPS levels were higher in the above median TAC group, although these findings were only marginally statistically significant and dependent on BMI adjustment. We observed n = 37 taxa to be significantly enriched among patients with > median TAC dose (all FDR<0.05), several of which are potential short-chain fatty acid producers with anti-inflammatory properties, including taxa from the family Subdoligranulum.

Conclusions: Our pilot study observed gut microbial alpha diversity to be increased while inflammation and oxidative stress were reduced among patients requiring higher TAC doses early after HT.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0233646PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7259664PMC
August 2020

Association Between "Unacceptable Condition" Expressed in Palliative Care Consultation Before Left Ventricular Assist Device Implantation and Care Received at the End of Life.

J Pain Symptom Manage 2020 11 25;60(5):976-983.e1. Epub 2020 May 25.

Department of Medicine, Adult Palliative Care Service, Columbia University Irving Medical Center, New York, New York, USA.

Context: Palliative care consultation before left ventricular assist device (LVAD) surgery (PreVAD) has been recommended, but its impact on goal-concordant care is unknown.

Objectives: To describe the association between patients' unique unacceptable condition articulated during PreVAD with the actual care provided at the end of life.

Methods: Among 308 patients who had PreVAD between 2014 and 2019, 72 patients died before December 31, 2019. Based on the answers to the question, "Is there any condition you would find unacceptable?" patients were divided into ARTICULATE (those who could articulate their unacceptable condition clearly, n = 58) and non-ARTICULATE (those who could not, n = 14). Circumstances at death and end-of-life care were compared between groups.

Results: Mean age at death was 63.2 years (SD ±13.1), 56 patients (77.8%) were males, and median duration of LVAD was 167.5 days (interquartile range 682). ARTICULATE patients died less frequently in the intensive care unit than non-ARTICULATE patients (33 patients, 57.9% vs. 13 patients, 92.9%; P = 0.014) and had ethics consultation less frequently (four patients, 6.9% vs. five patients, 35.7%; P = 0.011). Frequency of LVAD withdrawal was similar in both groups. Among ARTICULATE cohort, the unacceptable condition articulated in PreVAD did not seem to influence decisions at the end of life.

Conclusion: Patients who articulated their unacceptable condition clearly before LVAD surgery had less frequent ethics consultations and received less intensive care at the end of life, but it did not seem to affect the decision of LVAD withdrawal. It may be more important to engage in discussions around their unacceptable conditions, rather than the specific condition articulated. The question of an unacceptable condition should be part of any routine palliative care consultation before LVAD surgery.
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http://dx.doi.org/10.1016/j.jpainsymman.2020.05.025DOI Listing
November 2020

Local competition influences donor heart acceptance practice.

J Heart Lung Transplant 2020 08 27;39(8):835-838. Epub 2020 Apr 27.

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

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http://dx.doi.org/10.1016/j.healun.2020.04.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7721478PMC
August 2020

Gut microbiota, endotoxemia, inflammation, and oxidative stress in patients with heart failure, left ventricular assist device, and transplant.

J Heart Lung Transplant 2020 09 13;39(9):880-890. Epub 2020 Feb 13.

Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota; Division of Epidemiology, Mailman School of Public Health, Columbia University, New York City, New York. Electronic address:

Background: Gut microbial imbalance may contribute to endotoxemia, inflammation, and oxidative stress in heart failure (HF). Changes occurring in the intestinal microbiota and inflammatory/oxidative milieu during HF progression and following left ventricular assist device (LVAD) or heart transplantation (HT) are unknown. We aimed to investigate variation in gut microbiota and circulating biomarkers of endotoxemia, inflammation, and oxidative stress in patients with HF (New York Heart Association, Class I-IV), LVAD, and HT.

Methods: We enrolled 452 patients. Biomarkers of endotoxemia (lipopolysaccharide and soluble [sCD14]), inflammation (C-reactive protein, interleukin-6, tumor necrosis factor-α, and endothelin-1 adiponectin), and oxidative stress (isoprostane) were measured in 644 blood samples. A total of 304 stool samples were analyzed using 16S rRNA sequencing.

Results: Gut microbial community measures of alpha diversity were progressively lower across worsening HF class and were similarly reduced in patients with LVAD and HT (p < 0.05). Inflammation and oxidative stress were elevated in patients with Class IV HF vs all other groups (all p < 0.05). Lipopolysaccharide was elevated in patients with Class IV HF (vs Class I-III) as well as in patients with LVAD and HT (p < 0.05). sCD14 was elevated in patients with Class IV HF and LVAD (vs Class I-III, p < 0.05) but not in patients with HT.

Conclusions: Reduced gut microbial diversity and increased endotoxemia, inflammation, and oxidative stress are present in patients with Class IV HF. Inflammation and oxidative stress are lower among patients with LVAD and HT relative to patients with Class IV HF, whereas reduced gut diversity and endotoxemia persist in LVAD and HT.
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http://dx.doi.org/10.1016/j.healun.2020.02.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7423693PMC
September 2020

Impact of Induction Immunosuppression on Post-Transplant Outcomes of Patients Bridged with Contemporary Left Ventricular Assist Devices.

ASAIO J 2020 03;66(3):261-267

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

For patients bridged to transplant (BTT) with left ventricular assist devices (LVAD), data regarding the use of induction immunosuppressive therapy remain limited. The objectives of the current study were to describe the current trends and clinical consequences of IT in patients BTT with LVAD. The United Network of Organ Sharing database was queried to identify adult, single-organ heart transplant recipients who were BTT with LVAD between 2008 and 2018. Propensity score matching was then used to balance clinical covariates between those patient who did and did not receive IT. The primary outcomes of interest were graft survival, hospitalization for rejection and infection, and freedom from transplant coronary artery disease (TCAD). In the overall cohort, 49.1% (n = 3,978) received IT, with basiliximab being the most commonly used agent followed by antithymocyte globulin. After propensity score matching, 4,388 patients (2,194 without induction and 2,194 with induction) were identified. Between those who did and did not receive IT, there was no significant difference in graft survival, freedom from hospitalization for rejection, and freedom from hospitalization for infection. Patients who received IT experienced increased freedom from TCAD (p = 0.004) with unadjusted hazard ratio of 0.81 (95% Cardiac Index: 0.70-0.93). For freedom from TCAD, antithymocyte globulin was associated with better outcomes than basiliximab (80.2% vs. 73.1% at 5 years, log rank p value = 0.004). In a sensitivity analysis, there was no significant increase in hospitalization for infection in those patients with an infected LVAD before transplant. Use of induction therapy in patients BTT with LVAD appears to be safe and feasible, without a significant increase in the risk of infection or rejection, even in those patients with pretransplant device-related infections. IT, particularly antithymocyte globulin, was associated with increased time to development of TCAD. Routine use of IT in patients BTT with LVAD may be considered, and further randomized control trials are warranted to further support these data.
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http://dx.doi.org/10.1097/MAT.0000000000001119DOI Listing
March 2020

Association between recipient blood type and heart transplantation outcomes in the United States.

J Heart Lung Transplant 2020 04 21;39(4):363-370. Epub 2020 Jan 21.

Divisions of Cardiac Surgery, Columbia University Irving Medical Center, New York, New York.

Background: In heart transplantation (HT), although blood type O organs can go to any blood type, non-O organs may not be allocated to adult O recipients. Therefore, O candidates wait longer than non-O candidates and frequently require bridging with left ventricular assist devices (LVADs). The effects of this discrepancy are rarely investigated in a large registry. The purpose of this study was to assess the association between candidates' blood type and their outcomes after HT listing.

Methods: This is a retrospective cohort study using the United Network for Organ Sharing Registry, including 34,352 candidates listed for a single-organ, primary HT from January 2000 through December 2015. Main outcome measures were waitlist mortality and post-HT mortality, using blood type A as reference. We conducted inverse-probability weighting to adjust for baseline profiles.

Results: Among 34,352 candidates (median age 55, interquartile range 46-62; female 24.8%; blood type A: 13,258, AB: 1,572, B: 4,599, O:14,923), 22,714 candidates (A: 71.5%, AB: 82.1%, B: 73.0%, O: 57.5%; p < 0.001) underwent HT during the study period. Among recipients, bridging LVAD rate was highest in O recipients (A: 23.0%, AB: 15.3%, B: 23.4%, O: 32.1%; p < 0.001). After inverse-probability weighting, O patients demonstrated a significantly higher hazard of death after listing (adjusted hazard ratio 1.11, 95% confidence interval [CI] 1.07-1.16) and after HT (adjusted hazard ratio 1.07, 95% CI 1.01-1.13) as compared with A.

Conclusions: There is a survival discrepancy among blood types. Our findings should facilitate more prospective studies to revisit current policies regarding equity in allocation, where possible.
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http://dx.doi.org/10.1016/j.healun.2019.12.006DOI Listing
April 2020

Cystatin C- Versus Creatinine-Based Assessment of Renal Function and Prediction of Early Outcomes Among Patients With a Left Ventricular Assist Device.

Circ Heart Fail 2020 01 21;13(1):e006326. Epub 2020 Jan 21.

Division of Cardiology, Department of Medicine (A.P., G.M.M., E.A.R., M.M., A.G., A.M.Z., A.M., A.R.G., V.K.T., P.C.C., M.Y.), Columbia University Irving Medical Center, New York, NY.

Background: Estimated glomerular filtration rate (eGFR) based on serum creatinine (sCr) improves early after left ventricular assist device (LVAD) implantation but subsequently declines. Although sCr is a commonly accepted clinical standard, cystatin C (CysC) has shown superiority in assessment of renal function in disease states characterized by muscle wasting. Among patients with an LVAD, we aimed to (1) longitudinally compare CysC-eGFR and sCr-eGFR, (2) assess their predictive value for early postoperative outcomes, and (3) investigate mechanisms which might explain potential discrepancies.

Methods: A prospective cohort (n=116) with CysC and sCr concurrently measured at serial time points, and a retrospective cohort (n=91) with chest computed tomography performed within 40 days post-LVAD were studied. In the prospective cohort, the primary end point was a composite of in-hospital mortality, renal replacement therapy, or severe right ventricular failure. In the retrospective cohort, muscle mass was estimated using pectoralis muscle area indexed to body surface area (pectoralis muscle index).

Results: In the prospective cohort, sCr-eGFR significantly improved early post-LVAD and subsequently declined, whereas CysC-eGFR remained stable. CysC-eGFR but not sCr-eGFR predicted the primary end point: odds ratio per 5 mL/(min·1.73 m) decrease 1.16 (1.02-1.31) versus 0.99 (0.94-1.05). In retrospective cohort, for every 5 days post-LVAD, a 6% decrease in pectoralis muscle index was observed (95% CI, 2%-9%, =0.003). After adjusting for time on LVAD, for every 1 cm/m decrease in pectoralis muscle index, there was a 4% decrease in 30-day post-LVAD sCr (95% CI, 1%-6%, =0.004).

Conclusions: Initial improvement in sCr-eGFR is likely due to muscle wasting following LVAD surgery. CysC may improve assessment of renal function and prediction of early postoperative outcomes in patients with an LVAD.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.119.006326DOI Listing
January 2020

Response by Truby and Topkara to Letter Regarding Article, "Impact of Bridge to Transplantation With Continuous-Flow Left Ventricular Assist Devices on Posttransplantation Mortality: A Propensity-Matched Analysis of the United Network of Organ Sharing Database".

Circulation 2019 12 16;140(25):e942-e943. Epub 2019 Dec 16.

Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York (V.K.T.).

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http://dx.doi.org/10.1161/CIRCULATIONAHA.119.044323DOI Listing
December 2019

Endoscopic Algorithm for Management of Gastrointestinal Bleeding in Patients With Continuous Flow LVADs: A Prospective Validation Study.

J Card Fail 2020 Apr 1;26(4):324-332. Epub 2019 Dec 1.

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

Background: Gastrointestinal bleeding (GIB) is a common complication of left ventricular assist device (LVAD) therapy accounting for frequent hospitalizations and high resource utilization.

Methods: We previously developed an endoscopic algorithm emphasizing upfront evaluation of the small bowel and minimizing low-yield procedures in LVAD recipients with GIB. We compared the diagnostic and therapeutic yield of endoscopy, health-care costs, and re-bleeding rates between conventional GIB management and our algorithm using chi-square, Fisher's exact test, Wilcoxon-Mann-Whitney, and Kaplan-Meier analysis.

Results: We identified 33 LVAD patients with GIB. Presentation was consistent with upper GIB in 20 (61%), lower GIB in 5 (15%), and occult GIB in 8 (24%) patients. Forty-one endoscopies localized a source in 23 (56%), resulting in 14 (34%) interventions. Algorithm implementation compared with our conventional cohort was associated with a 68% increase in endoscopic diagnostic yield (P< .01), a 113% increase in therapeutic yield (P= .01), a 27% reduction in the number of procedures per patient (P < .01), a 33% decrease in length of stay (P < .01), and an 18% reduction in estimated costs (P < .01). The same median number of red blood cell transfusions were used in the 2 cohorts, with no increase in re-bleeding events in the algorithm cohort (33.3%) compared with our conventional cohort (43.7%).

Conclusions: Our endoscopic management algorithm for GIB in LVAD patients proved effective in reducing low-yield procedures, improving the diagnostic and therapeutic yield of endoscopy, and decreasing health-care resource utilization and costs, while not increasing the risk of a re-bleeding event.
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http://dx.doi.org/10.1016/j.cardfail.2019.11.027DOI Listing
April 2020

Clinical Outcomes After Left Ventricular Assist Device Implantation in Older Adults: An INTERMACS Analysis.

JACC Heart Fail 2019 12;7(12):1069-1078

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

Objectives: The purpose of this study was to examine outcomes after left ventricular assist device (LVAD) implantation in older adults (>75 years of age).

Background: An aging heart failure population together with improvements in mechanical circulatory support (MCS) technology have led to increasing LVAD implantations in older adults. However, data presenting age-specific outcomes are limited.

Methods: Adult patients in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) who required durable MCS between 2008 and 2017 were included. Patients were stratified by 4 age groups: <55 years of age, 55 to 64 years of age, and >75 years of age. Kaplan-Meier survival estimates were used to assess post-LVAD outcomes, with log-rank testing used to compare groups. Univariate and multivariate cox proportional hazard regression models were used to determine predictors of survival and complications.

Results: A total of 20,939 individuals received an LVAD during the study period: 7,743 (37.0%) were <55 years of age, 6,755 (32.3%) were 55 to 64 years of age, 5,418 (25.9%) were 65 to 74 years of age, and 1,023 (4.9%) were ≥75 years of age or older. After multivariate adjustment, adults ≥75 years of age had increased mortality post-LVAD implantation. Elderly patients with LVADs had a higher incidence of gastrointestinal bleeding but lower rates of device thrombosis. Compared to 84.5% of patients <55 years of age who were discharged home, only 46.8% of adults ≥75 years of age were discharged home following implantation (p < 0.001). Use of a RVAD, serum albumin level, and 6-min walk test distances were identified as predictors of outcomes in the oldest cohort.

Conclusions: Despite careful selection of older adults for LVAD implantation, age remains a significant predictor of mortality. Higher bleeding and lower clotting risk in elderly patients with LVADs support the use of a less intense antithrombotic regimen in this unique population.
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http://dx.doi.org/10.1016/j.jchf.2019.10.004DOI Listing
December 2019

Effect of Pulmonary Hypertension on Transplant Outcomes in Patients With Ventricular Assist Devices.

Ann Thorac Surg 2020 07 23;110(1):158-164. Epub 2019 Nov 23.

Division of Cardiac Surgery, Columbia University Medical Center, New York, New York.

Background: Although extremely high pulmonary vascular resistance (PVR) is a relative contraindication for heart transplantation (HTx), recent data with continuous-flow left ventricular assist devices (LVADs) indicate HTx outcomes may be different when high PVR is managed with an LVAD. This study clarifies the contemporary association between PVR at HTx and posttransplant survival in LVAD vs non-LVAD cohorts.

Methods: We reviewed the United Network for Organ Sharing registry for adults who received a transplant from 2008 to 2015. In those with continuous-flow LVADs and those with no VADs at HTx, (non-VAD), we grouped patients by low PVR (PVR <3), intermediate PVR (PVR 3 to <6), and high PVR (PVR ≥6) groups. Adjusted hazard ratios (aHRs) for death after HTx were calculated by Cox regression.

Results: The non-LVAD cohort included 6270 patients (4385 in low, 1643 in intermediate, and 242 in high PVR), and the LVAD cohort included 4111 patients (3227 in low, 798 in intermediate, and 86 in high PVR). The high PVR LVAD group had the worst survival, which was not significant, likely to low power (P = .300). The aHR for death in non-LVAD was 1.047 (95% confidence interval, 1.010-1.088) and in LVAD was 1.063 (95% confidence interval, 1.010-1.119). Cubic spline analysis demonstrated nonlinear associations between PVR and the aHR, especially in the LVAD cohort.

Conclusions: There was no significant evidence to conclude the effect of pretransplant PVR on posttransplant survival is higher in LVAD vs non-LVAD patients, based on analysis of the United Network for Organ Sharing database. However, further investigations are indicated to clarify HTx candidacy in those with extremely high PVR even after LVAD.
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http://dx.doi.org/10.1016/j.athoracsur.2019.09.095DOI Listing
July 2020

Impact of Obesity on Ventricular Assist Device Outcomes.

J Card Fail 2020 Apr 13;26(4):287-297. Epub 2019 Oct 13.

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

Background: Obesity remains a relative contraindication for heart transplantation, and hence, obese patients with advanced heart failure receive ventricular assist devices (VADs) either as a destination or "bridge to weight loss" strategy. However, impact of obesity on clinical outcomes after VAD implantation is largely unknown. We sought to determine the clinical outcomes of obese patients with body mass index (BMI) ≥ 35 kg/m) following contemporary VAD implantation.

Methods: The Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) registry was queried for patients who underwent VAD implantation. Patients were categorized into BMI groups based on World Health Organization classification.

Results: Of 17,095 patients, 2620 (15%) had a BMI ≥ 35 kg/m. Obese patients were likely to be young, non-white, females with dilated cardiomyopathy and undergo device implantation as destination. Survival was similar amongst BMI groups (P = .058). Obese patients had significantly higher risk for infection (hazard ratio [HR]: 1.215; P = .001), device malfunction or thrombosis (HR: 1.323; P ≤ .001), cardiac arrhythmia (HR: 1.188; P = .001) and hospital readmissions (HR: 1.073; P = .022), but lower risk of bleeding (HR: 0.906; P = .018). Significant weight loss (≥10%) during VAD support was achieved only by a small proportion (18.6%) of patients with BMI ≥ 35 kg/m. Significant weight loss rates observed in obese patients with VAD implantation as destination and bridge to transplant strategy were comparable. Obese patients with significant weight loss were more likely to undergo cardiac transplantation. Weight loss worsened bleeding risk without altering risk for infection, cardiac arrhythmia, and device complications.

Conclusions: Obesity alone should not be considered a contraindication for VAD therapy in contemporary era. Given durability of heart transplantation, strategies should be developed to promote weight loss, which occurs infrequently in obese patients. Impact of weight loss on clinical outcome of obese patients warrants further investigation.
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http://dx.doi.org/10.1016/j.cardfail.2019.10.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141964PMC
April 2020

Withdrawal of Left Ventricular Assist Devices: A Retrospective Analysis from a Single Institution.

J Palliat Med 2020 03 10;23(3):368-374. Epub 2019 Oct 10.

Adult Palliative Care, Department of Medicine, Columbia University Medical Center, New York, New York.

When left ventricular assist device (LVAD) therapy no longer is able to achieve patients' desired quality of life, withdrawal of LVAD therapy (WLVAD) may be requested. To evaluate factors associated with WLVAD, including the time taken before WLVAD. Sixty-two patients who newly underwent initial LVAD therapy during January 1, 2010 and October 30, 2018 and subsequently underwent WLVAD by December 31, 2018 were divided into those who participated in the decision of WLVAD (defined as PT+,  = 14), and those who could not participate in the decision because of the medical reasons (defined as PT-,  = 48). Time to WLVAD in PT+ and PT- was defined as WD_PT+ (days between patients' request and WLVAD) and WD_PT- (days between when patients became unable to express themselves and WLVAD), respectively. Circumstances around WLVAD, including location of death and use of palliative care (PC), were reviewed. Mean age at WLVAD was 65.4 ± 10.1 years and 52 (83.9%) were men. Median days on LVAD support was 166.5 days (interquartile range = 838). The majority of WLVAD occurred in the intensive care unit (ICU) (83.6%) but less frequent in PT+ than in PT- (64.3% vs. 89.4%,  = 0.041). The median number of PC visits in the last month was higher in PT+ than in PT- (4.5 vs. 0.5,  = 0.005). The median WD_PT+ was 5.5 days and was significantly shorter in the ICU (1 day vs. 46 days,  = 0.013). The median WD_PT- was 5.5 days and tended to be shorter in the ICU (4 days vs. 13 days,  = 0.072). A multivariate analysis showed that male gender and ICU setting were both negatively associated with WD_PT- ( = 0.025 for men,  = 0.005 for ICU setting). The majority of WLVAD occurred in the ICU and required PC involvement. Time to WLVAD was shorter in the ICU. Requests for WLVAD directly made by patients, especially in a non-ICU setting, seemed to have posed more difficulty.
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http://dx.doi.org/10.1089/jpm.2019.0322DOI Listing
March 2020

Left Ventricular Assist Device Therapy in Older Adults: Addressing Common Clinical Questions.

J Am Geriatr Soc 2019 11 10;67(11):2410-2419. Epub 2019 Aug 10.

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

Objectives: To review the literature and summarize the evidence for left ventricular assist device (LVAD) use in older adults (aged >75 years), highlighting patient selection, day-to-day life with an LVAD, age-specific complications, and end-of-life considerations.

Design: Contemporary review of current literature on LVAD therapy in older adults.

Results: There is a paucity of data on LVAD use and outcomes in adults older than 75 years and even less commonly are such devices implanted in those older than 80 years. Candidates and recipients of this age often have multiple chronic conditions and extracardiac impairments, which can negatively affect their short-term outcomes and daily experience following LVAD implantation. Therefore, selection prior to implant should incorporate end-organ function, nutritional status, measures of frailty, neurocognitive status, and social support, among others, to determine the patient population most likely to benefit from such therapy.

Conclusion: When LVAD therapy is utilized in an older adult, the needs for multidisciplinary team management and expertise in palliative care are essential. More age-specific outcome data are required to help inform providers, patients, and caregivers. J Am Geriatr Soc 67:2410-2419, 2019.
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http://dx.doi.org/10.1111/jgs.16105DOI Listing
November 2019

Acute kidney injury following left ventricular assist device implantation: Contemporary insights and future perspectives.

J Heart Lung Transplant 2019 08 19;38(8):797-805. Epub 2019 Jun 19.

Thoraxcenter, Department of Cardiology, Unit Heart Failure, Heart Transplantation & Mechanical Circulatory Support. Electronic address:

Currently, an increasing number of patients with end-stage heart failure are being treated with left ventricular assist device (LVAD) therapy as bridge-to-transplantation, bridge-to-candidacy, or destination therapy (DT). Potential life-threatening complications may occur, specifically in the early post-operative phase, which positions LVAD implantation as a high-risk surgical procedure. Acute kidney injury (AKI) is a frequently observed complication after LVAD implantation and is associated with high morbidity and mortality. The rapidly growing number of LVAD implantations necessitates better approaches of identifying high-risk patients, optimizing peri-operative management, and preventing severe complications such as AKI. This holds especially true for those patients receiving an LVAD as DT, who are typically older (with higher burden of comorbidities) with impaired renal function and at increased post-operative risk. Herein we outline the definition, diagnosis, frequency, pathophysiology, and risk factors for AKI in patients with an LVAD. We also review possible strategies to prevent and manage AKI in this patient population.
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http://dx.doi.org/10.1016/j.healun.2019.06.001DOI Listing
August 2019

Impact of Bridge to Transplantation With Continuous-Flow Left Ventricular Assist Devices on Posttransplantation Mortality.

Circulation 2019 08 17;140(6):459-469. Epub 2019 Jun 17.

Division of Cardiology, Department of Medicine (M.A.F., A.R.G., R.G., S.W.R., F.L., V.K.T.), Columbia University College of Physicians and Surgeons, New York, NY.

Background: Bridge to transplantation (BTT) with left ventricular assist devices (LVADs) is a mainstay of therapy for heart failure in patients awaiting heart transplantation (HT). Criteria for HT listing do not differ between patients medically managed and those mechanically bridged to HT. The objectives of the present study were to evaluate the impact of BTT with LVAD on posttransplantation survival, to describe differences in causes of 1-year mortality in medically and mechanically bridged patients, and to evaluate differences in risk factors for 1-year mortality between those with and those without LVAD at the time of HT.

Methods: Using the United Network of Organ Sharing database, we identified 5486 adult, single-organ HT recipients transplanted between 2008 and 2015. Patients were propensity matched for likelihood of LVAD at the time of HT. Kaplan-Meier survival estimates were used to assess the impact of BTT on 1- and 5-year mortality. Logistic regression analysis was used to evaluate the odds ratio of 1-year mortality for patients BTT with LVAD compared with those with medical management across clinically significant variables at various thresholds.

Results: Early mortality was higher in mechanically bridged patients: 9.5% versus 7.2% mortality at 1 year (P<0.001). BTT patients incurred an increased risk of 1-year mortality with an estimated glomerular filtration rate of 40 to 60 mL·min·1.73 m (odds ratio, 1.69; P=0.003) and <40 mL·min·1.73 m (odds ratio, 2.16; P=0.005). A similar trend was seen in patients with a body mass index of 25 to 30 kg/m (odds ratio, 1.88; P=0.024) and >30 kg/m (odds ratio, 2.11; P<0.001). When patients were stratified by BTT status and the presence of risk factors, including age >60 years, estimated glomerular filtration rate <40 mL·min·1.73 m, and body mass index >30 kg/m, there were significant differences in 1-year mortality between medium- and high-risk medically and mechanically bridged patients, with 1-year mortality in high-risk BTT patients at 17.6% compared with 10.4% in high-risk medically managed patients.

Conclusions: Bridge to HT with LVAD, although necessary because of organ scarcity and capable of improving wait list survival, confers a significantly higher risk of early posttransplantation mortality. Patients bridged with mechanical support may require more careful consideration for transplant eligibility after LVAD placement.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.118.036932DOI Listing
August 2019