Gregg M. Lanier

The Impella 5.5 is a surgically implanted micro‐axial left ventricular assist device (LVAD) increasingly utilized for mechanical circulatory support (MCS) in cardiogenic shock. While typically used for acute support up to FDA‐approved 14 days, reports of prolonged utilization remain limited. We present the case of a 69‐year‐old male who presented with severe biventricular failure and cardiogenic shock who was bridged to heart transplantation (HT) utilizing a single Impella 5.5 for a total of 276 days. His prolonged support course was managed through a multidisciplinary approach addressing recurrent ventricular arrhythmias, renal failure, heparin‐induced thrombocytopenia, and device management (suction alarms and purge flow limitations). Following successful HT, the explanted device demonstrated no mechanical injury or thrombus, and pathologic examination revealed no significant device‐related structural heart damage. The patient was discharged without major complications and continued to do well at 5‐month follow‐up.

Cardiomyopathy is a rare but serious adverse effect of long-term hydroxychloroquine therapy, manifesting as conduction abnormalities and heart failure. Its incidence is not well established. We pre...

Background: Obesity is an established risk factor for cardiometabolic disease and heart failure (HF). Nevertheless, the relationship between obesity and HF mortality remains controversial. Results: The goal of this study was to describe the prevalence of obesity in patients hospitalized for HF in Egypt and investigate the relationship of obesity to cardiometabolic risk factors, HF phenotype and mortality. Between 2011 and 2014, 1661 patients hospitalized for HF across Egypt were enrolled as part of the European Society of Cardiology HF Long-term Registry. Obese patients, defined by a BMI ≥ 30 kg/m², were compared to non-obese patients. Factors associated with mortality on univariate analysis were entered into a logistic regression model to identify whether obesity was an independent predictor of mortality during hospitalization and at one-year follow-up. The prevalence of obesity was 46.5% and was higher in females compared to males. Obese as compared to non-obese patients had a higher prevalence of diabetes mellitus (47.0% vs 40.2%, p = 0.031), hypertension (51.3% vs 33.0%, p < 0.001) and history of myocardial infarction (69.2% vs 62.8% p = 0.005). Obese patients as compared to non-obese patient were more likely to have acute coronary syndrome on admission (24.8% vs 14.2%, p < < 0.001). The dominant HF phenotype in obese and non-obese patients was HF with reduced ejection fraction (EF); however, obese patients as compared to non-obese patient had higher prevalence of HF with preserved EF (22.3% vs 12.4%, p < 0.001). Multivariable analysis demonstrated that obesity was associated with an independent survival benefit during hospitalization, (OR for mortality 0.52 [95% CI 0.29–0.92]). Every point increase in BMI was associated with an OR = 0.93 [95% CI 0.89–0.98] for mortality during hospitalization. The survival benefit was not maintained at one-year follow-up. Conclusions: Obesity was highly prevalent among the study cohort and was associated with higher prevalence of cardiometabolic risk factors as compared to non-obese patients. Obesity was associated with an independent “protective effect” from in-hospital mortality but was not a predictor of mortality at 1-year follow-up.

Pleural effusions appearing within the first 30 postoperative days following coronary artery bypass grafting are classified as early and believed to be directly related to cardiac surgery. The characteristics of such effusions are well-described. Orthotopic heart transplantation is also known to be complicated by pleural effusions, but their characteristics have not been systematically reported. We assessed the features of early postoperative pleural effusions after heart transplantation and compared them to those of early effusions following coronary artery bypass grafting. We retrospectively collected demographic, clinical, and laboratory data for patients who underwent either orthotopic heart transplantation (study group) or coronary artery bypass grafting (comparison group) at our institution and whose postoperative course within 30 days was complicated by new or worsening pleural effusion. Patients subjected to analysis consisted only of those with sufficiently complete laboratory profiles to permit adequate characterization of the nature of their pleural fluid. Out of 251 orthotopic heart transplant recipients, 7 (2.8%) were found to have sufficiently complete pleural fluid results to be included. Out of 1506 patients who underwent coronary artery bypass grafting, 32 (2.1%) had sufficiently complete pleural fluid results. The radiological appearance of pleural effusions in both groups was similar: bilateral in at least half and exclusively moderate to large. Effusions complicating both surgeries were exudative in close to 90% of cases. For those with available leukocyte differential counts, the pleural fluid of the post-orthotopic heart transplantation group was more often neutrophilic (3/5, 60%), whereas the fluid of the post-coronary artery bypass grafting group was more often lymphocytic (22/32, 69%) and tended to be hemorrhagic (median red blood cell count 33,000 cells/µl vs 10,000 cells/µl). None of the comparisons of pleural fluid characteristics between the two groups reached statistical significance. This small, descriptive study is the first to systematically report the fluid characteristics of pleural effusions complicating orthotopic heart transplantation within the first 30 postoperative days and to compare this group to those who developed effusions after coronary artery bypass grafting. Our findings revealed both similarities and differences in the pleural fluid characteristics between these two types of patients.

The co-existence of hypertrophic obstructive cardiomyopathy (HOCM) and pulmonary arterial hypertension (PAH) is extremely rare and poses a management conundrum. This is the first case report in the published literature to describe the diagnosis and management of a patient with both conditions. A 49-year-old female with a history of HOCM and recently diagnosed scleroderma presented to the clinic with progressive dyspnoea. Transthoracic echocardiogram demonstrated left ventricular outflow tract (LVOT) obstruction at rest, and elevated pulmonary artery (PA) pressure. Cardiac catheterization (CC) demonstrated an LVOT gradient of 150 mmHg, PA pressure of 88/32 mmHg, pulmonary capillary wedge pressure (PCWP) 12 mmHg, pulmonary vascular resistance 14.8 Wu, and a cardiac index of 1.6 L/min/m². The differential diagnosis for the dyspnoea included combined pre- and post-capillary pulmonary hypertension from longstanding HOCM vs. scleroderma associated PAH. Tadalafil was added to the patient’s medical regimen of metoprolol but it was stopped because the patient developed pulmonary oedema. Alcohol septal ablation was undertaken with improvement in the LVOT gradient, but only a modest improvement in her dyspnoea. Repeat CC demonstrated worsening PAH. Vasodilatory testing with nitric oxide led to an improvement in the PA pressure with minimal increase of the PCWP. Hence, she was started on treprostinil and macitentan, with significant improvement in her dyspnoea on follow-up. In patients with concurrent HOCM and advanced PAH, a multidisciplinary treatment approach is needed to rapidly and safely optimize the background of HOCM in order to permit the use of PAH-specific medications.

Background: The association of obesity on outcomes in patients with cardiogenic shock requiring acute mechanical circulatory support has not been thoroughly investigated. Methods: We evaluated the National Readmission Database for adults with either acute myocardial infarction or heart failure complicated by cardiogenic shock requiring acute mechanical circulatory support between January 2016 and November 2017. Exposure was assessed using International Classification of Diseases , Tenth Revision codes for the degree of obesity with the reference being body mass index (BMI) of 20.0 to 29.9 group. Multiple logistic regression and Cox regression analysis were used to analyze in-hospital mortality and 30-day readmission, respectively. Results: The survey-weighted sample included a total of 35 555 hospitalizations with a mean age of 65.4±0.2 years and 29.8% females. Obesity was associated with higher in-hospital mortality (no obesity, 26.4% [BMI, 20.0–29.9] versus class I obesity, 25.0% [BMI, 30.0–34.9] versus class II obesity, 28.7% [BMI, 35.0–39.9] versus class III obesity, 34.9% [BMI, ≥40]; P P =0.02; odds ratio, 2.1 [95% CI, 1.2–3.7], P =0.01) and older adults (age ≥60) with class III obesity (odds ratio, 1.7 [95% CI, 1.2–2.4], P =0.005) had higher mortality. There was no association between the degree of obesity and 30-day readmission. Conclusions: Among adults with acute myocardial infarction or acute heart failure resulting in cardiogenic shock requiring acute mechanical circulatory support, younger adults with class II and class III obesity and older patients with class III obesity have a higher risk of in-hospital mortality compared with nonobese patients.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a form of pulmonary hypertension (PH) caused by thromboembolic disease with the secondary remodeling of the pulmonary vessels. The primary treatment of CTEPH is pulmonary thromboendarterectomy (PTE). However, some patients are not candidates for PTE because of surgically inaccessible thrombi or high operative risk and can be candidates for balloon pulmonary angioplasty (BPA), an emerging, lower risk treatment. This review discusses the patient selection, the technique, and comprehensive review of reported outcomes following BPA. BPA techniques have improved over the years, and so has its safety profile. Recent data show that after several sessions of BPA, patients who were not eligible for PTE had improvement in their hemodynamic profile, functional capacity, and 6-minute walk distance. Studies have shown that compared to riociguat, BPA has shown significant improvement in the functional capacity and hemodynamic measurements. Reperfusion pulmonary edema is a common complication after PTE and BPA, which may be due to vessel injury rather than pulmonary extravasation. Rates of complications have decreased especially after the use of optical coherence tomography, which helps in proper sizing of the balloons. Patients with CTEPH who are ineligible for PTE should be evaluated for BPA. In addition to medical therapy, BPA has shown promising clinical and hemodynamic outcomes in patients with CTEPH.