Research Spotlight

Lam, P. H., M. Packer, G. S. Gill, W. C. Wu, W. C. Levy, M. R. Zile, V. Brar, C. Arundel, Y. Cheng, S. N. Singh, R. M. Allman, G. C. Fonarow and A. Ahmed (2020). “Digoxin Initiation and Outcomes in Patients with Heart Failure with Preserved Ejection Fraction.” Am J Med Apr 6. pii: S0002-9343(20)30236-9. [Epub ahead of print].

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BACKGROUND: Digoxin reduces the risk of heart failure hospitalization in patients with heart failure with reduced ejection fraction (HFrEF). Less is known about this association in patients with heart failure with preserved ejection fraction (HFpEF), the examination of which was the objective of the current study. METHODS: In the Medicare-linked OPTIMIZE-HF registry, 7374 patients hospitalized for HF had ejection fraction >/=50% who were not receiving digoxin before admission. Of these, 5675 had a heart rate >/=50 beats/minute, an estimated glomerular filtration rate (eGFR) >/=30 mL/min/1.73 m(2) or did not receive inpatient dialysis, and digoxin was initiated in 524 of these patients. Using propensity scores for digoxin initiation, calculated for each of the 5675 patients, we assembled a matched cohort of 513 pairs of patients initiated and not initiated on digoxin, balanced on 58 baseline characteristics (mean age, 80 years; 66% women; 8% African American). Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes associated with digoxin initiation were estimated in the matched cohort. RESULTS: Among the 1026 matched patients with HFpEF, 30-day heart failure readmission occurred in 6% and 9% of patients initiated and not initiated on digoxin, respectively (HR, 0.70; 95% CI, 0.45-1.10; p=0.124). HRs (95% CIs) for 30-day all-cause readmission and all-cause mortality associated with digoxin initiation were 0.95 (0.73-1.23; p=0.689) and 0.93 (0.55-1.56; p=0.773), respectively. Digoxin initiation had no association with 6-year outcomes. CONCLUSION: Digoxin initiation before hospital discharge was not associated with 30-day or 6-year outcomes in older hospitalized patients with HFpEF.

Kumano, K., M. C. Lawrence, N. Onaca, M. F. Levy and B. Naziruddin (2020). “Successful allogeneic islet transplantation after total pancreatectomy with islet autotransplantation to restore normoglycemia: a case report.” Acta Diabetol 57(5): 619-622.

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CP is a debilitating, irreversible disease of the pancreas that often leads to intractable pain and diabetes. The goal of TPIAT is to remove the exocrine pancreas as the source of pain and replace the islets to prevent postsurgical brittle diabetes and hypoglycemic unawareness. TPIAT significantly improves patients’ long-term quality of life after the surgery. (Excerpt from text; no abstract available.)

Klintmalm, G. B. and R. T. Gunby, Jr. (2020). “Successful Pregnancy in a Liver Transplant Recipient on Belatacept: A Case Report.” Liver Transpl Apr 26. [Epub ahead of print].

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A 35-year-old woman experienced chronic antibody-mediated rejection (cAMR) after her first and second liver transplantations. After the second transplant with cAMR, belatacept was started, with normalization of her liver function. Two years later, she became pregnant. She was continued on belatacept together with low doses of slow-release tacrolimus, azathioprine, and steroids. Her pregnancy was uneventful and her child healthy, with none of the frequent complications seen in pregnancies during immunosuppression. Although belatacept is not yet approved by the US Food and Drug Administration in liver transplantation, its role in specific liver transplant recipients should be considered.E

Kiselica, A. M., T. A. Webber and J. F. Benge (2020). “Using multivariate base rates of low scores to understand early cognitive declines on the uniform data set 3.0 Neuropsychological Battery.” Neuropsychology Apr 27. [Epub ahead of print].

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OBJECTIVE: Low neuropsychological test scores are commonly observed even in cognitively healthy older adults. For batteries designed to assess for and track cognitive decline in older adults, documenting the multivariate base rates (MBRs) of low scores is important to differentiate expected from abnormal low score patterns. Additionally, it is important for our understanding of mild cognitive impairment and preclinical declines to and determine how such score patterns predict future clinical states. METHOD: The current study utilized Uniform Data Set Neuropsychological Battery 3.0 (UDS3NB) data for 5,870 English-speaking, older adult participants from the National Alzheimer’s Coordinating Center from 39 Alzheimer’s disease Research Centers from March 2015 to December 2018. MBRs of low scores were identified for 2,608 cognitively healthy participants that had completed all cognitive measures. The association of abnormal MBR patterns with subsequent conversion to mild cognitive impairment and dementia were explored. RESULTS: Depending on the operationalization of “low” score, the MBR of demographically adjusted scores ranged from 1.40 to 79.2%. Posttest probabilities using MBR methods to predict dementia status at 2-year follow up ranged from .06 to .33, while posttest probabilities for conversion to mild cognitive impairment (MCI) ranged from .12-.32. CONCLUSIONS: The data confirm that abnormal cognitive test scores are common among cognitively normal older adults. Using MBR criteria may improve our understanding of MCI. They may also be used to enrich clinical trial selection processes through recruitment of at-risk individuals.

Khan, Z., M. Hamandi, H. Khan, J. M. DiMaio and M. Evans (2020). “Convergent epicardial-endocardial ablation for treatment of long-standing persistent atrial fibrillation: A review of literature.” J Card Surg Apr 25. [Epub ahead of print].

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BACKGROUND AND AIM OF STUDY: The convergent procedure (CVP) is a hybrid ablation technique via a subxiphoid incision that has recently emerged as a treatment option for non-paroxysmal atrial fibrillation (npAF). By combining endocardial and epicardial ablation into a simultaneous or staged procedure, the pulmonary vein and posterior left atrium can be isolated with transmural lesion sets while minimizing the risk of proarrhythmic gaps that are a known limitation with endocardial linear lesion sets. We reviewed the 12-month outcomes in patients who underwent CVP compared to those who underwent endocardial catheter ablation (CA) and surgical ablation (SA). METHODS: A literature search was conducted using the PubMed database for publications related to CVP. Selected studies included detailed 12-month follow-up of patients, patient characteristics, periprocedural complications, use of antiarrhythmic drugs (AADs), and monitoring method. RESULTS: Five studies with 340 patients who underwent CVP between January 2009 and March 2017 were selected for this review. A total of 8.5% of patients had paroxysmal AF (pAF), 42.2% had persistent AF (peAF), and 49.1% had long-standing persistent AF (lspAF). At 12 months, 81.9% of patients were in sinus rhythm, while 54.1% of patients were in sinus rhythm while not taking AADs. The overall complication rate was 10%. CONCLUSION: CVP had better 1-year efficacy in eliminating AF when compared to CA. However, SA, specifically the Cox Maze IV, had lower rates of AF recurrence in the npAF patient population. Despite its promising 1-year efficacy rates, the periprocedural complication rate for CVP was significantly higher than both CA and SA.