Amit Alam M.D.

Alam, A., Mancini, D. and Hall, S. (2021). “Should Withdrawal Of Care Be Listed As A Cause Of Death?” Ann Thorac Surg Mar 19;S0003-4975(21)00534-8. [Epub ahead of print].

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In the latest INTERMACS report we were encouraged to read that despite the heart failure community implanting left ventricular assist devices (LVAD) in a sicker patient population, survival continues to improve. However, the frequent adverse events and the primary cause of death remain concerning. Major bleeding and infection continue to lead the adverse events profile with a declining rate of strokes. Interestingly, the report does not track incidence of right sided heart failure which had been included in prior annual INTERMACS reports. Furthermore, the report concludes that “withdrawal of care” is now the leading cause of death. [No abstract, excerpt from article].

Alam, A., Kobashigawa, J., Milligan, G.P. and Hall, S.A. (2021). “Evolution of Testing for Allograft Rejection After Orthotopic Heart Transplantation Without the Evolution of Guidelines and a Proposal for the Multidisciplinary Health-Team Approach.” Am J Cardiol Mar 19;S0002-9149(21)00254-X. [Epub ahead of print].

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Acute allograft rejection remains among the most common causes of morbidity and mortality, especially in the first year following orthotopic heart transplant with roughly 25% of patients having at least 1 episode of allograft rejection within this time period. Despite its prevalence and substantial clinical significance, accurate diagnosis often proves elusive. Endomyocardial biopsy (EMB) remains the gold standard in diagnosis of acute rejection,2 despite its inherent limitations of sampling bias, subjectivity, and false negatives are well known. This has prompted the use of an expanding array of diagnostic modalities such as cardiac magnetic resonance imaging, gene expression profiling, donor-derived cell free DNA (dd-cfDNA), and more recently, microarray biopsy technology known as the Molecular Microscope Diagnostic System (MMDx). Recommendations on the utility of some of these tests were provided in the latest guidelines on care of the heart transplant recipient published by the International Society of Heart and Lung Transplant in 2010, however, as the field has rapidly evolved, so must our approach to the care of these patients. [No abstract; excerpt from article].

Moreyra, A.E., Cosgrove, N.M., Zinonos, S., Yang, Y., Cabrera, J., Pepe, R.J., Alam, A., Kostis, J.B., Lee, L. and Kostis, W.J. (2021). “Constrictive Pericarditis after Open Heart Surgery: A 20-Year Case Controlled Study.” Int J Cardiol Jan 6;S0167-5273(20)34338-2. [Epub ahead of print].

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BACKGROUND: Constrictive pericarditis is a rare complication of open heart surgery (OHS), but little is known regarding the etiologic determinants, and prognostic factors. The purpose of this study was to investigate clinical predictors and long term prognosis of post-operative constrictive pericarditis (CP). METHODS: Using the Myocardial Infarction Data Acquisition System database, we analyzed records of 142,837 patients who were admitted for OHS in New Jersey hospitals between 1995 and 2015. Ninety-one patients were hospitalized with CP 30 days or longer after discharge from OHS. Differences in proportions were analyzed using Chi square tests. Controls were matched to cases for demographics, surgical procedure type, history of OHS, and propensity score. Cox proportional hazard models were used to evaluate the risk of all-cause death. Log-rank tests and Cox models were used to assess differences in the Kaplan-Meier survival curves with and without adjustments for comorbidities. RESULTS: Patients with CP were more likely to have history of valve disease (VD, p < 0.001), atrial fibrillation (AF, p = 0.024) renal disease (CKD, p = 0.028), hemodialysis (HD, p = 0.008), previous OHS (p < 0.001). Patients with CP compared to matched controls had a higher 7-year mortality (p < 0.001). This difference became statistically significant at 1-year after surgery. CONCLUSION: CP is a rare complication of OHS that occurs more frequently in patients with VD, AF, CKD, HD, multiple OHS, and it is associated with an unfavorable long-term prognosis. Given the large number of OHS performed every year, the results highlight the need for clinicians to recognize and properly manage this complication of OHS.

Alam, A., Milligan, G.P. and Joseph, S.M. (2020). “Reconsidering the Diagnostic Criteria of Right Ventricular Primary Graft Dysfunction.” J Card Fail Aug 7;S1071-9164(20)30901-5. [Epub ahead of print.].

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Primary graft dysfunction is defined as left and/or right ventricular (RV) failure occurring in the immediate post-transplant period in the absence of an immunologic or anatomic etiology. It is the leading cause of peri-operative mortality among patients receiving heart transplants1 making early and accurate diagnosis critical to optimizing outcomes. Diagnostic criteria were proposed by the International Society of Heart and Lung Transplantation,2 however the diagnosis of right ventricular primary graft dysfunction (RV-PGD) remains controversial. We review the currently accepted diagnostic criteria for RV-PGD, detail their inherent limitations, and propose a simplified approach to diagnosis and classification of RV-PGD severity. [No abstract available; excerpt from article.].

Milligan, G. P., A. Alam and C. Guerrero-Miranda (2020). “Recognizing Right Ventricular Dysfunction in Coronavirus Disease-2019-Related Respiratory Illness.” J Card Fail May 11;S1071-9164(20)30497-8. [Epub ahead of print].

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We have read the article by Tersalvi and colleagues1 detailing mechanisms of elevated troponin in patients with coronavirus disease 2019 (COVID-19), and we write to encourage recognition of acute right ventricular (RV) strain as an additional possibility. [No abstract; excerpt from article].