Faculty Bibliography

Advanced heart failure (AHF) is associated with increased morbidity and mortality, and greater healthcare utilization. Recognition requires a thorough clinical assessment and appropriate risk stratification. There are persisting inequities in the allocation of AHF therapies. Women are less likely to be referred for evaluation of candidacy for heart transplantation or left ventricular assist device despite facing a higher risk of AHF-related mortality. Sex-specific risk factors influence progression to advanced disease and should be considered when evaluating women for advanced therapies. The purpose of this review is to discuss the role of sex hormones on the pathophysiology of AHF, describe the clinical presentation, diagnostic evaluation and definitive therapies of AHF in women with special attention to pregnancy, lactation, contraception and menopause. Future studies are needed to address areas of equipoise in the care of women with AHF.

Purpose: The presentation of Coronavirus disease 2019 (COVID-19) ranges from mild illness to severe respiratory failure. Disease progression may differ in immunocompromised patients and immunocompetent hosts. Therefore, we aim to characterize COVID-19 clinical presentation and outcomes in solid organ transplant recipients (SOTRs) to identify initial clinical factors that may predict COVID-19 associated mortality.
Method(s): We prospectively reviewed baseline demographic and clinical characteristics among adult kidney, pancreas, liver, heart and lung transplant recipients diagnosed with COVID-19 between March 1, 2020 and May 5, 2020 at our transplant center in New York City. A series of chi-square and Fisher's exact tests were conducted to investigate the relationship between several predictor variables (baseline characteristics, symptoms at presentation, and baseline immunosuppression regimen) and 30-day mortality.
Result(s): 73 SOTRs (53 kidney, 8 liver, 7 heart, 3 lung, 2 heart/kidney) with SARSCoV-2 PCR-confirmed COVID-19 were included in the final analysis. Median age was 59 years (IQR 54-68) and 34.2% were female. Median time since transplant was 21 months (IQR 13-46.5). All patients were on baseline immunosuppresion as shown in table 1. The majority of patients were diagnosed in the Emergency Department. Most common presenting symptoms were cough (68.5%), gastrointestinal symptoms (54.8%) and dyspnea (45.2%) with median of 5 days from symptom onset to hospitalization. All patients had elevated inflammatory markers at time of diagnosis (median CRP 54 mg/L, median ferritin 704 ng/mL, median procalcitonin 0.11 ng/mL, median D-dimer 311 ng/mL). 84.1% of patients required supplemental oxygen, including intubation in 19.7%. 13 of 63 (21%) hospitalized patients died. Dyspnea on presentation was the only baseline or presenting patient factor found to be predictive of death (p =.004). When stratified by initial chest X-ray findings, dyspnea combined with abnormal chest X-ray predicted mortality (p=.021) while dyspnea with normal chest X-ray did not.
Conclusion(s): Presenting symptoms of dyspnea and radiographic signs of pneumonia on initial imaging predicted mortality among SOTRs with COVID-19 in our cohort. These findings can inform allocation of limited resources in COVID-19 management, including the triage and timing of COVID-19 directed therapies early in the illness course among different patient populations

BACKGROUND/UNASSIGNED:There is a lack of robust data evaluating outcomes of enoxaparin "bridge" therapy in left ventricular assist device (LVAD) patients. METHODS/UNASSIGNED:We performed a retrospective study of HeartMate II (HM II) and HeartWare HVAD recipients that received therapeutic enoxaparin as "bridge" therapy to describe bleeding and thrombotic events and compare outcomes between devices. The primary endpoint was the incidence of bleeding within 30 days of "bridge" episode. Major bleeding was defined by INTERMACS criteria. RESULTS/UNASSIGNED:= .02). We observed 3 (1%) thromboembolic events in 2 (4%) patients with an HVAD device. On multivariate analysis, the presence of a HM II device was associated with a 4-fold increased risk of bleeding. CONCLUSION/UNASSIGNED:We found the use of enoxaparin "bridge" therapy to be associated with a higher incidence of bleeding in patients with a HM II device compared with an HVAD device. Assessment of device- and patient-specific factors should be evaluated to minimize bleeding events.

Purpose: During the COVID 19- pandemic, there is no consensus on management strategies for treating infected heart transplant patients. The outcomes of these patients vary by institution. We report our center experience and management strategies to date.
Method(s): All patients who received heart transplantation, from January 4th 2018 to September 25th 2020 and were diagnosed with SARS-CoV-2 were included and full chart review was performed.
Result(s): There were 113 heart transplants at our institution by September 2020. A total of 13 (12%) patients were infected with SARS-CoV-2: 9 (69%) isolated heart, 3 heart -kidney (23%) and 1 heat- lung (8%). The median (IQR) time from transplant to diagnosis was 10 (5-16) months. The mean age was 57 years and 50% were male; 50% were of Hispanic ethnicity. The main presenting symptoms were fever (43%), cough (86%) and SOB (43%). Chest x-ray was abnormal in all patients. We evaluated all patients and 79% were hospitalized and 21% were closely monitored as outpatients. None of our patients were hospitalized at outside institutions. Two (14%) required intubation and none required V-V ECMO support. The immunotherapy was modified in all patients: MMF and prednisone were discontinued, tacrolimus dose was reduced. COVID19 treatment was: 71% received hydroxychloroquine, 50% azithromycin, 15% remdesevir, 7% convalescent plasma. All hospitalized patients received anticoagulation. One patient had 2R/3A rejection within 30 days prior to diagnosis. Graft function was maintained in all patients with median LVEF% 65 (59-65%) except one patient who had received thymoglobulin 2 weeks prior to COVID 19 infection (LVEF 30%). The patient had a prolonged intubation but ultimately recovered and was discharged from the hospital. The one death (7.1%) was a heart - kidney recipient who concomitantly presented with pseudomonas sepsis and severe neutropenia. The remaining patients have all been discharged home.
Conclusion(s): We present our single center experience in managing COVID 19 infected heart transplant patients. We implemented uniform management strategies by incorporating aggressive reduction of immunosuppression, frequent scheduled contacts with infected outpatients and making sure all infected patients requiring hospitalization were treated at a transplant center.
Copyright

Pump thrombosis remains a feared complication for patients implanted with durable left ventricular assist devices. Optimal treatment is unknown, but consists of either pharmacologic fibrinolysis or surgical pump exchange. Fibrinolysis is less invasive, but carries a significant risk of intracerebral hemorrhage. We present four cases of LVAD pump thrombosis successfully treated with a novel protocol that consists of low-dose four-factor prothrombin complex concentrate to reverse baseline INR elevation prior to alteplase administration to minimize the risk for intracerebral hemorrhage.

BACKGROUND:The Impella (Abiomed) ventricular support system is a family of temporary mechanical circulatory support (MCS) devices used to treat patients with cardiogenic shock, acute cardiogenic decompensation, and for high-risk percutaneous or surgical revascularization. These devices include the percutaneously implanted 2.5/cardiac power (CP) and the surgically implanted 5.0/left direct (LD). Despite the beneficial effects and increased usage of these devices, data to assess adverse outcomes and guide clinician decision-making between the Impella CP and 5.0/LD are limited. METHODS:This is a retrospective analysis of 91 consecutive patients who required at least 24 h of Impella support, from January 1, 2015 to December 31, 2019. Groups were stratified based on either initial Impella CP or 5.0/LD placement. Clinical outcomes and in-hospital complications were compared. RESULTS:Impella CP was implanted in 66 patients (mean age: 61 ± 15 years, male 71.2%) and Impella 5.0/LD was implanted in 25 patients (mean age: 62 ± 9 years, male 84.0%). There was greater stability of device position (p = .033), less incidence of hemolysis (p < .001), and less frequent need for additional MCS (p = .001) in patients implanted with the Impella 5.0/LD compared with Impella CP in this study cohort. Patients with Impella 5.0/LD were more likely to survive from Impella and survive to discharge. CONCLUSIONS:This study suggests that for patients who require temporary MCS for more than 24 h, the Impella 5.0/LD may have a more favorable device-specific adverse profile compared with the Impella CP.