Cardiology

Dewan, P., A. Jackson, P. S. Jhund, L. Shen, J. P. Ferreira, M. C. Petrie, W. T. Abraham, A. S. Desai, K. Dickstein, L. Kober, M. Packer, J. L. Rouleau, S. D. Solomon, K. Swedberg, M. R. Zile and J. J. V. McMurray (2020). “The prevalence and importance of frailty in heart failure with reduced ejection fraction – an analysis of PARADIGM-HF and ATMOSPHERE.” Eur J Heart Fail Apr 30. [Epub ahead of print].

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AIMS: Frailty, characterized by loss of homeostatic reserves and increased vulnerability to physiological decompensation, results from an aggregation of insults across multiple organ systems. Frailty can be quantified by counting the number of ‘health deficits’ across a range of domains. We assessed the frequency of, and outcomes related to, frailty in patients with heart failure and reduced ejection fraction (HFrEF). METHODS AND RESULTS: Using a cumulative deficits approach, we constructed a 42-item frailty index (FI) and applied it to identify frail patients enrolled in two HFrEF trials (PARADIGM-HF and ATMOSPHERE). In keeping with previous studies, patients with FI 0.210). The frailest patients were older and had more symptoms and signs of heart failure. Women were frailer than men. All outcomes were worse in the frailest, with high rates of all-cause death or all-cause hospitalization: 40.7 (39.1-42.4) vs. 22.1 (21.2-23.0) per 100 person-years in the non-frail; adjusted hazard ratio 1.63 (1.53-1.75) (P < 0.001). The rate of all-cause hospitalizations, taking account of recurrences, was 61.5 (59.8-63.1) vs. 31.2 (30.3-32.2) per 100 person-years (incidence rate ratio 1.76; 1.62-1.90; P < 0.001). CONCLUSION: Frailty is highly prevalent in HFrEF and associated with greater deterioration in quality of life and higher risk of hospitalization and death. Strategies to prevent and treat frailty are needed in HFrEF.

Cox, J., W. C. Roberts, F. G. Araj, J. Jarzembowski, C. Y. Guerrero-Miranda, A. Cooley, C. S. Roberts and D. M. Meyer (2020). “Acute Isolated Coronary Artery Dissection Causing Massive Acute Myocardial Infarction and Leading to Unsuccessful Coronary Bypass, Extracorporeal Life Support, and Successful Cardiac Transplantation.” Am J Cardiol 125(9): 1446-1448.

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Described herein is a 42-year-old woman who suddenly developed a spontaneous isolated coronary arterial dissection which led to massive acute myocardial infarction with shock, unsuccessful coronary artery bypass grafting, transiently successful extracorporeal life support, and finally successful heart transplant. Such a sequence of events is exceedingly rare for patients with coronary dissection and prompted this report.

Cedars, A., K. M. Tecson, A. N. Zaidi, A. Lorts and P. A. McCullough (2020). “Impact of Durable Ventricular Assist Device Support on Outcomes of Patients with Congenital Heart Disease Waiting for Heart Transplant.” Asaio j 66(5): 513-519.

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The number of congenital heart disease (CHD) patients with heart failure is expanding. These patients have a high probability of dying while awaiting heart transplant. The potential for durable ventricular assist devices (VAD) to improve waiting list survival in CHD is unknown. We conducted an analysis of the Scientific Registry of Transplant Recipients database for the primary outcome of death or delisting due to clinical worsening while listed for heart transplant. We compared CHD patients with non-CHD patients matched for listing status. Multivariable models were constructed to account for confounding variables. Congenital heart disease patients were less likely to have a VAD and were more likely to experience the primary outcome of death or delisting due to clinical worsening compared to non-CHD patients. Ventricular assist devices decreased the probability of experiencing the primary outcome for non-CHD but not for CHD patients with a final listing status of 1A. Ventricular assist devices increased the probability of experiencing the primary outcome among CHD patients for those with a final listing status of 1B with no impact in non-CHD patients. Among non-CHD patients who died or were delisted, the time to the primary outcome was delayed by VAD, with a similar trend in CHD. Except for patients with a final listing status of 1B, VAD does not adversely affect waiting list outcomes in CHD patients listed for heart transplant. Ventricular assist devices may prolong waiting list survival among high-risk CHD patients.

Arnold, S. V., G. W. Stone, M. J. Mack, A. K. Chhatriwalla, B. A. Austin, Z. Zhang, O. Ben-Yehuda, S. Kar, D. S. Lim, J. Lindenfeld, W. T. Abraham and D. J. Cohen (2020). “Health Status Changes and Outcomes in Patients With Heart Failure and Mitral Regurgitation: COAPT Trial.” J Am Coll Cardiol 75(17): 2099-2106.

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BACKGROUND: In the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trial, transcatheter mitral valve repair (TMVr) with the MitraClip rapidly improved health status and reduced the long-term risks for death and heart failure (HF) hospitalization in patients with HF and severe secondary mitral regurgitation who remained symptomatic despite maximally tolerated guideline-directed medical therapy (GDMT). OBJECTIVES: The aim of this study was to examine if early health status changes were associated with long-term clinical outcomes in the COAPT population. METHODS: The association between change in health status (Kansas City Cardiomyopathy Questionnaire overall summary score [KCCQ-OS]) from baseline to 1 month and the composite rate of death or HF hospitalization between 1 month and 2 years in the COAPT trial were evaluated, and whether treatment (TMVr or GDMT alone) modified this association was tested. RESULTS: Among 551 patients with HF and severe secondary mitral regurgitation who were alive at 1 month, those randomized to TMVr were more likely than those randomized to GDMT alone to achieve a >/=10-point improvement in KCCQ-OS from baseline to 1 month (TMVr, 58%; GDMT alone, 26%). Early improvement in KCCQ-OS was inversely associated with the risk for death or HF hospitalization between 1 month and 2 years (p < 0.001). When analyzed as a continuous variable, a 10-point increase in KCCQ-OS was associated with a 14% lower risk for death or HF hospitalization (hazard ratio: 0.86; 95% confidence interval: 0.81 to 0.92; p < 0.001), with no significant interaction with treatment group (pinteraction = 0.17). After adjusting for demographic and clinical factors, the association between change in KCCQ-OS and outcomes was strengthened (hazard ratio: 0.79; 95% confidence interval: 0.73 to 0.86; p < 0.001). CONCLUSIONS: In patients with HF and severe secondary mitral regurgitation, a short-term change in disease-specific health status was strongly associated with the subsequent long-term risk for death or HF hospitalization. These findings reinforce the prognostic utility of serial KCCQ-OS assessments to identify patients at risk for poor long-term clinical outcomes in this population. (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation [The COAPT Trial]; NCT01626079).

Amin, S. D., K. B. Homan, M. Assar, M. Lee and C. D. Housewright (2020). “Hyfrecation and Interference With Implantable Cardiac Devices.” Dermatol Surg 46(5): 612-615.

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BACKGROUND: Mohs micrographic surgery, excisional surgery, and electrodessication and curettage (ED&C) are common dermatologic procedures that often use electrodessication through hyfrecators to achieve hemostasis. According to in vitro studies, electrodessication is considered safe in patients with implanted cardiac devices. To the authors’ knowledge, there are no in vivo data to support this claim. OBJECTIVE: In this study, the authors aim to describe the outcomes of hyfrecation during dermatologic procedures in patients with pacemakers and implantable cardiac devices. METHODS: Retrospective chart review was completed from March 2014 to April 2018 at a single center. Forty-five patients met criteria of having a cardiac device and having undergone an electrosurgery procedure using the Conmed 2000 Hyfrecator (Utica, NY). Adverse perioperative and postoperative outcomes, as well as device malfunction, were evaluated. RESULTS: No adverse perioperative effects were reported. Device reports were examined for inappropriate firing of the defibrillator, loss of capture, temporary inhibition of pacing, battery drainage, pacing at an elevated or erratic rate, failure to deliver antitachycardia, reversion to asynchronous pacing, induction of arrhythmias, or tissue damage at lead tissue, but no such issues were found. CONCLUSION: The lack of complications associated with cardiac devices with hyfrecation is reassuring. However, prospective and larger retrospective studies are warranted.