Faculty Bibliography

PURPOSE/OBJECTIVE:Cardiac rehabilitation (CR) is beneficial in heart transplant and left ventricular assist device (LVAD) recipients, but patterns of attendance remain poorly understood. We describe CR adherence and cessation in this population. METHODS:We performed a retrospective review of heart transplant and LVAD recipients who attended ≥1 CR session at a tertiary medical center (2013-2022). Complete adherence was defined as attending 36 sessions. Primary reasons for cessation before 36 sessions were recorded. We compared post-operative complications, duration of hospitalization, and readmissions between participants with and without complete adherence using logistic and linear regressions. Among participants with complete adherence, we compared changes in metabolic equivalent of task (MET), exercise time, and peak oxygen uptake using paired sample t tests. RESULTS:There were 137 heart transplant and LVAD recipients (median age 56.9 years, 74% male) who attended CR. Among them, 91% either completed 36 CR sessions or <24 sessions. Among those without complete adherence (n = 74), 72% reported medical reasons, and 15% reported personal reasons for cessation. Compared to those who completed CR, those without complete adherence experienced more post-operative complications (44% vs 24%, P = .02) and major bleeding (23% vs 7%, P = .02) prior to CR. Participants with complete adherence experienced significant improvements in exercise time (142.5 seconds), MET (0.4), and peak oxygen uptake (1.4 mL/kg/min). CONCLUSIONS:Nearly half of heart transplant and LVAD recipients in CR completed all 36 sessions. Those with complete adherence experienced significant improvements in exercise measures, underscoring the important benefits of CR in this population.

Background As the number of adults with congenital heart disease increases because of therapeutic advances, cardiac rehabilitation (CR) is increasingly being used in this population after cardiac procedures or for reduced exercise tolerance. We aim to describe the adherence and exercise capacity improvements of patients with adult congenital heart disease (ACHD) in CR. Methods and Results This retrospective study included patients with ACHD in CR at New York University Langone Rusk Rehabilitation from 2013 to 2020. We collected data on patient characteristics, number of sessions attended, and functional testing results. Pre-CR and post-CR metabolic equivalent task, exercise time, and maximal oxygen uptake were assessed. In total, 89 patients with ACHD (mean age, 39.0 years; 54.0% women) participated in CR. Referral indications were reduced exercise tolerance for 42.7% and post-cardiac procedure (transcatheter or surgical) for the remainder. Mean number of sessions attended was 24.2, and 42 participants (47.2%) completed all 36 CR sessions. Among participants who completed the program as well as pre-CR and post-CR functional testing, metabolic equivalent task increased by 1.3 (95% CI, 0.7-1.9; baseline mean, 8.1), exercise time increased by 66.4 seconds (95% CI, 21.4-111.4 seconds; baseline mean, 536.1 seconds), and maximal oxygen uptake increased by 2.5 mL/kg per minute (95% CI, 0.7-4.2 mL/kg per minute; baseline mean, 20.2 mL/kg per minute). Conclusions On average, patients with ACHD who completed CR experienced improvements in exercise capacity. Efforts to increase adherence would allow more patients with ACHD to benefit.

Background Cardiac rehabilitation (CR) is increasingly being prescribed for adult congenital heart disease (ACHD) patients after cardiac procedures or for reduced exercise tolerance. We aim to describe the functional capacity improvements of ACHD patients in CR. Methods This retrospective study included ACHD patients at NYU Rusk Cardiac Rehabilitation from 2013-2019. We collected data on patient characteristics, number of sessions attended, and exercise testing results. Paired sample t-tests were used to assess for changes between pre- and post-CR exercise time and metabolic equivalents (METs). Results In total, 76 ACHD patients (mean age 38.2 years, 56.6% female, 89.5% moderate or complex conditions by anatomic classification) participated in CR. Referral indication was reduced exercise tolerance for 43.4% and was post-cardiac procedure (transcatheter or surgical) for the remainder. Among 37 patients (48.7%) who finished all 36 CR sessions, complete exercise testing data was available for 29 of them. Exercise time increased by 83.8 seconds (95% CI, 43.9 - 123.8; baseline mean 520.7), METs increased by 1.2 (95% CI, 0.6 - 1.8; baseline mean 8.1), and both parameters increased for 72.4% of these patients. These statistically significant improvements were observed across referral indications. Conclusion On average, CR benefits ACHD patients who complete the program, regardless of referral indication. Efforts to increase CR referral and retention would allow more patients to benefit. [Formula presented]
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BACKGROUND: The recent AHA/ACC guidelines on duration of dual anti-platelet therapy (DAPT) recommend DAPT for 1 year in patients presenting with an acute coronary syndrome, with a Class IIb recommendation for continuation. We aim to assess the evidence for these recommendations using a meta-analytic approach. METHODS: We searched electronic databases for randomized trials comparing short-term (12 months) DAPT in patients with an acute coronary syndrome undergoing percutaneous coronary intervention. We evaluated all-cause mortality, cardiovascular mortality, myocardial infarction, stent thrombosis and major bleeding. A random effects model was used to calculate pooled relative risk (RR) and 95% confidence intervals (CI). RESULTS: We included 8 trials comprising of 12,917 patients with an acute coronry syndrome; 5 trials compared short-term vs 12 months/extended DAPT, whereas 3 trials compared 12 months vs extended DAPT. There was no significant difference in cardiovascular mortality (RR: 1.04, 95% CI: 0.67-1.60), MI (RR: 1.08, 95% CI: 0.79-1.47) or major bleeding (RR: 0.91, 95% CI: 0.49-1.69) between short-term versus 12 months/extended DAPT. However, compared to extended DAPT, 12 months DAPT showed significantly higher risk of myocardial infarction (RR: 2.00, 95% CI: 1.47-2.73) but reduced risk of major bleeding (RR: 0.58, 95% CI: 0.34-0.98). All-cause mortality was found to be similar between 12 months vs extended DAPT. CONCLUSIONS: In acute coronary syndrome, short-term DAPT may be reasonable for some patients whereas extended DAPT may be appropriate in select others. An individualized approach is needed taking into account the competing risks of bleeding and ischemic events.

Background: The recent AHA/ACC guidelines on duration of dual anti-platelet therapy (DAPT) recommends DAPT for 1 year in patients presenting with acute coronary syndrome (ACS) and undergoing percutaneous coronary intervention (PCI), with a Class IIb recommendation for continuation. Methods: We searched electronic databases to identify randomized trials comparing short-term (<=6 months) vs 12 months vs extended (>12 months) DAPT in patients with ACS undergoing PCI. We evaluated allcause and cardiovascular mortality, myocardial infarction (MI), stent thrombosis and major bleeding. Random effects modeling was used to calculate pooled relative risk (RR) and 95% confidence intervals (CI). Results: We included 8 trials comprising of 12,917 ACS patients; 5 trials compared short-term vs 12 months or extended DAPT, whereas 3 trials compared 12 months vs extended DAPT. There were no significant differences in either ischemic or bleeding outcomes between short-term vs 12 months or extended DAPT. However compared to extended DAPT, 12 months DAPT showed significantly higher risk of MI (RR 2.00, 95% CI: 1.47 to 2.73, p<0.001) but reduced risk of major bleeding (RR 0.58, 95% CI: 0.34 to 0.98, p=0.04). All-cause mortality was similar between 12 months vs extended DAPT. The heterogeneity was low to moderate (I2 ranged from 17% to 39%). Conclusion: In ACS, DAPT beyond 1 year should be based on an individualized patient approach taking into account the competing risks of bleeding and ischemic complications. (Table Presented)

Introduction: Epilepsy patients have more than twentyfold greater risk of death when compared to the general population and it often occur at night or in relation to sleep. Prior studies have found that specific cardiorespiratory abnormalities occurred more preferentially during sleep as compared to wakefulness in adult epilepsy patients. Whether nocturnal seizures are more likely to be associated with higher oxygen desaturation drop is uncertain. Therefore, we examined the temporal pattern of oxygen saturation before, during, and after seizures occurring either during sleep or wakefulness. Methods: Respiratory measures were retrospectively examined in 40 recorded seizures from 20 adult patients with epilepsy (11 female; 22-53 years old) admitted for long-term video-EEG monitoring at the Brigham and Women's Hospital. Oxygen saturation levels were analyzed at 4 time-points: 1) Preictally (10-s before seizure onset), 2) ictally (during a seizure), 3) immediately postictally (10-s after a seizure), and 4) 5-min postictally (5 minutes after a seizure). Results: Seventeen (43%) seizures occurred during sleep and 23 (58%) during wakefulness. Seizure duration did not differ between sleep and wake states. Seizures from sleep were associated with lower nadir oxygen saturation as compared to seizures from wakefulness, both during a seizure and immediately after a seizure (ps < 0.05). Seizures from sleep were also associated with a significantly larger desaturation drop as compared to seizures from wakefulness across all time-points (-7.6 +/- 4.6 and -2.9 +/- 1.8, respectively; p < 0.05). Conclusion: Despite comparable oxygen saturation levels at baseline (preictally), our results show that seizures occurring during sleep are associated with larger oxygen desaturation drop as compared to wakefulness. Moreover, during nocturnal seizures, oxygen saturation levels remain significantly lower, even few seconds after seizure termination. These findings suggest that nocturnal seizures are more likely to be associated with more severe and longer hypoxemia events, which might have some implication for sudden death in epilepsy patients

A 48-year-old male with history of chronic arthritis and uveitis presented with 1 year of progressively reduced exercise capacity and nonexertional chest pain. Physical examination was consistent with severe aortic insufficiency. An electrocardiogram demonstrated sinus rhythm with first degree atrioventricular block. Transthoracic and transesophageal echocardiography demonstrated severe lone central aortic insufficiency of a trileaflet valve due to leaflet thickening, retraction of leaflet margins and mild aortic root dilation in the setting of left ventricular dilatation. In addition, computed tomographic angiography revealed a small focal aneurysm of the distal transverse arch. He was found to be positive for the immunogenetic marker HLA-B27. The patient subsequently underwent uncomplicated mechanical aortic valve replacement. The diagnosis of HLA-B27 associated cardiac disease should be entertained in any individual with lone aortic insufficiency, especially if accompanied by conduction disease.

We studied whether the use of sirolimus with reduced-dose tacrolimus, as compared to standard-dose tacrolimus, after liver transplantation is safe, tolerated and efficacious. In an international multicenter, open-label, active-controlled randomized trial (2000-2003), adult primary liver transplant recipients (n = 222) were randomly assigned immediately after transplantation to conventional-dose tacrolimus (trough: 7-15 ng/mL) or sirolimus (loading dose: 15 mg, initial dose: 5 mg titrated to a trough of 4-11 ng/mL) and reduced-dose tacrolimus (trough: 3-7 ng/mL). The study was terminated after 21 months due to imbalance in adverse events. The 24-month cumulative incidence of graft loss (26.4% vs. 12.5%, p = 0.009) and patient death (20% vs. 8%, p = 0.010) was higher in subjects receiving sirolimus. A numerically higher rate of hepatic artery thrombosis/portal vein thrombosis was observed in the sirolimus arm (8% vs. 3%, p = 0.065). The incidence of sepsis was higher in the sirolimus arm (20.4% vs. 7.2%, p = 0.006). Rates of acute cellular rejection were similar between the two groups. Early use of sirolimus using a loading dose followed by maintenance doses and reduced-dose tacrolimus in de novo liver transplant recipients is associated with higher rates of graft loss, death and sepsis when compared to the use of conventional-dose tacrolimus alone.

Tumor necrosis factor alpha (TNF-alpha) antagonists are being increasingly used as maintenance therapies for rheumatic diseases, and therefore knowledge of their adverse effects is important. We report a case of fatal acute necrotizing eosinophilic myocarditis temporally related to use of a second course of the TNF-alpha antagonist, adalimumab. A 51-year-old woman with relapsing polychondritis took adalimumab 2 weeks before presenting with acute myocarditis. Within hours of presentation to the emergency department, she had cardiac arrest due to fulminant heart failure. Autopsy demonstrated necrotizing eosinophilic myocarditis. This is a rare cause of fulminant heart failure. This is the first report of a TNF-alpha antagonist potentially associated with acute necrotizing eosinophilic myocarditis.