Baylor Heart and Vascular Institute

O’Hair, D. P., T. K. Bajwa, S. J. Chetcuti, G. M. Deeb, R. C. Stoler, R. F. Hebeler, B. Maini, M. Mumtaz, N. S. Kleiman, M. J. Reardon, S. Li, D. H. Adams, D. R. Watson, S. J. Yakubov, J. J. Popma and G. Petrossian (2017). “One-year outcomes of transcatheter aortic valve replacement in patients with end-stage renal disease.” Ann Thorac Surg: 2017 Feb [Epub ahead of print].

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BACKGROUND: End-stage renal disease (ESRD) poses unique challenges in the treatment of patients with severe aortic stenosis. Although surgical valve replacement in ESRD patients has been associated with increased mortality, the outcomes from transcatheter aortic valve replacement (TAVR) are not clearly defined. METHODS: The CoreValve US Expanded Use Study is a prospective, nonrandomized study of TAVR in extreme-risk patients with comorbidities excluding them from the Pivotal Trial. We report on patients with ESRD. The primary endpoint was a composite of all-cause mortality or major stroke at 1 year. RESULTS: Ninety-six patients with ESRD underwent TAVR with the CoreValve (Medtronic, Minneapolis, MN) and have reached 1-year follow-up. Mean Society of Thoracic Surgeons Predicted Risk of Mortality score was 16.2% +/- 8.4%. The rate of all-cause mortality or major stroke at 1 year was 30.3%. The all-cause mortality rate was 5.3% at 30 days and 30.3% at 1 year. The rate at 1 year of any stroke or transient ischemic attack was 2.1%; major vascular injury was 5.2%; and new permanent pacemaker was 26.8%. Valve performance improved postprocedure and remained improved at 1 year (effective orifice area 1.71 cm2, mean gradient 9.33 mm Hg) CONCLUSIONS: Early mortality in patients with ESRD is comparable to previously published data on extreme-risk patients without ESRD, but our data suggest a higher mortality rate at 1 year for ESRD patients, likely due to comorbid conditions. Stroke and major vascular injury are infrequent, and improved valve hemodynamics are maintained at 1 year.

Jordan, S., J. Karcher, R. Rogers, K. Kennedy, A. Lawrence and J. Adams (2017). “Measurement of functional capacity requirements of farmers: Implications for a cardiac rehabilitation training program.” J Cardiopulm Rehabil Prev 37(2): 119-123.

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PURPOSE: Updated cardiac rehabilitation (CR) and return-to-work guidelines from the American College of Sports Medicine (ACSM) now include specificity of training for industrial athletes (exercise training that involves the muscle groups, movements, and energy systems that these patients use during occupational tasks). However, many CR facilities do not apply this principle, relying instead on the traditional protocol that consists primarily of aerobic exercise. This study was conducted to measure the metabolic cost of typical farming tasks and to compare 2 methods of calculating training intensities. METHODS: Metabolic data were collected from 28 participants (23 men and 5 women, aged 18 to 57 years) while they loaded 10 hay bales, dug a fence posthole, filled 8 seed hoppers, and shoveled grain. RESULTS: Mean metabolic equivalent levels during these activities were 5.9 to 7.6 and participants reached 60% to 70% of heart rate reserve (HRR). By comparison, their mean resting heart rate + 30 beats per minute (RHR+30, a traditional CR intensity level) represented only 28% of HRR. CONCLUSIONS: Participants in the current study performed farming tasks within the ACSM’s recommended range of 40% to 80% of HRR, and the results suggest that training at RHR+30 would have been inadequate for helping a farmer return to work after a cardiac event. Using the study tasks as a basis, we described exercises that would be appropriate for the supervised resistance training of farmers in a CR setting.

Carey, S. A., K. Bass, G. Saracino, C. A. East, J. Felius, P. A. Grayburn, R. C. Vallabhan and S. A. Hall (2017). “Probability of accurate heart failure diagnosis and the implications for hospital readmissions.” Am J Cardiol: 2017 Jan [Epub ahead of print].

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Heart failure (HF) is a complex syndrome with inherent diagnostic challenges. We studied the scope of possibly inaccurately documented HF in a large health care system among patients assigned a primary diagnosis of HF at discharge. Through a retrospective record review and a classification schema developed from published guidelines, we assessed the probability of the documented HF diagnosis being accurate and determined factors associated with HF-related and non-HF-related hospital readmissions. An arbitration committee of 3 experts reviewed a subset of records to corroborate the results. We assigned a low probability of accurate diagnosis to 133 (19%) of the 712 patients. A subset of patients were also reviewed by an expert panel, which concluded that 13% to 35% of patients probably did not have HF (inter-rater agreement, kappa = 0.35). Low-probability HF was predictive of being readmitted more frequently for non-HF causes (p = 0.018), as well as documented arrhythmias (p = 0.023), and age >60 years (p = 0.006). Documented sleep apnea (p = 0.035), percutaneous coronary intervention (p = 0.006), non-white race (p = 0.047), and B-type natriuretic peptide >400 pg/ml (p = 0.007) were determined to be predictive of HF readmissions in this cohort. In conclusion, approximately 1 in 5 patients documented to have HF were found to have a low probability of actually having it. Moreover, the determination of low-probability HF was twice as likely to result in readmission for non-HF causes and, thus, should be considered a determinant for all-cause readmissions in this population.

Corzo, G. and G. P. Espino-Solis (2017). “Selected scorpion toxin exposures induce cytokine release in human peripheral blood mononuclear cells.” Toxicon 127: 56-62.

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A cytokine screening on human peripheral blood mononuclear cells (PBMCs) stimulated with selected scorpion toxins (ScTx’s) was performed in order to evaluate their effect on human immune cells. The ScTx’s chosen for this report were three typical buthid scorpion venom peptides, one with lethal effects on mammals Centruroides suffussus suffusus toxin II (CssII), another, with lethal effects on insects and crustaceans Centruroides noxius toxin 5 (Cn5), and one more without lethal effects Tityus discrepans toxin (Discrepin). A Luminex multiplex analysis was performed in order to determine the amounts chemokines and cytokines IL-1beta, IL-2, IL-4, IL-5, IL-6, IL-10, IL-12-p40, IL-13, interferon alpha (IFN-alpha), interferon gamma (IFN-gamma), tumor necrosis factor alpha TNF-alpha, and interferon-inducible protein-10 (IP-10) secreted from human PBMCs exposed to these toxins. Although, the ScTx Cn5 is not lethal for mammals, it was able to induce the secretion of cytokines IL-1beta, IL-6, and TNF-alpha, IL-10 and IP-10 in comparison to the lethal CssII, which was able to induce only IP-10 secretion. Discrepin also was able to induce only IP-10. Interestingly, only low amounts of interferons alpha and beta were induced in the presence of the ScTx’s assayed. In a synergic experiment, the combination of Discrepin and Cn5 displayed considerable reverse effects on induction of IL-1beta, IL-6, IL-10 and TNF-alpha, but they had a slight synergic effect on IP-10 cytokine production in comparison with the single effect obtained with the Cn5 alone. Thus, the results obtained suggest that the profile of secreted cytokines promoted by ScTx Cn5 is highly related with a cytokine storm event, and also it suggests that the mammalian lethal neurotoxins are not solely responsible of the scorpion envenomation symptomatology.

Fendler, T. J., M. E. Nassif, K. F. Kennedy, S. M. Joseph, S. C. Silvestry, G. A. Ewald, S. J. LaRue, J. M. Vader, J. A. Spertus and S. V. Arnold (2017). “Global outcome in patients with left ventricular assist devices.” Am J Cardiol: 2017 Jan [Epub ahead of print].

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Left ventricular assist devices (LVADs) improve survival and quality of life (QOL) for most, but not all, patients with advanced heart failure. We described a broader definition of poor outcomes after LVAD, using a novel composite of death, QOL, and other major adverse events. We evaluated the frequency of poor global outcome at 1 year after LVAD among 164 patients (86% Interagency Registry for Mechanically Assisted Circulatory Support profile 1 to 2; shock or declining despite inotropes) at a high-volume center. Poor global outcome (comprising death, poor QOL [Kansas City Cardiomyopathy Questionnaire <45], recurrent heart failure [>/=2 heart failure readmissions], or severe stroke) occurred in 58 patients (35%): 37 died, 17 had poor QOL, 3 had recurrent heart failure, and 1 had a severe stroke. Patients with poor global outcomes were more likely designated for destination therapy (46% vs 24%, p = 0.01), spent more days hospitalized per month alive (median [interquartile range] 18.6 [5.0 to 31.0] vs 3.7 [1.8 to 8.3], p <0.001), and had higher intracranial (12% vs 2%, p = 0.031) and gastrointestinal (44% vs 28%, p = 0.056) hemorrhage rates over the year after implant. Although LVADs often improve survival and QOL, approximately 1/3 of high-acuity patients experienced a poor global outcome over the year after LVAD. In conclusion, composite outcomes may better capture events that matter to patients with LVADs and thus support informed decisions about pursuing LVAD therapy.