Faculty Bibliography

Durable left ventricular assist devices (dLVAD) remain a lifesaving therapy in patients with stage D heart failure that is refractory to conventional medical therapies. Owing to improvements in technology and patient outcomes, the number of patients supported with dLVADs has increased over the past decade. Despite this growing population, there are few resources for cardiovascular intensivists that integrate epidemiology, diagnostic workup and multidisciplinary medical management of acute emergencies in patients supported with dLVADs.

Iron deficiency has been reported in up to 50% of patients with heart failure (HF), irrespective of the presence of anemia. Although no formally validated definition for iron deficiency in patients with HF exists, both the American and European Heart Failure Guidelines define iron deficiency as a serum ferritin of < 100 ng/ml, or a ferritin of 100-299 ng/ml, provided that the transferrin saturation (TSAT) is less than 20%. The presence of iron deficiency has been associated with poor patient-oriented outcomes, prompting the assessment of intravenous (IV) iron as a treatment for iron deficiency. This review summarizes the totality of the evidence on the diagnosis, evaluation and treatment of patients with iron deficiency. In addition, we highlight our approach to patients with HF with reduced ejection fraction and highlight areas for both clinical improvement and research.

OBJECTIVES/OBJECTIVE:To evaluate the efficacy of intraoperative hemoadsorption (HA) during cardiopulmonary bypass (CPB) in reducing acute kidney injury (AKI) and other major postoperative complications in patients undergoing cardiac surgery. DESIGN/METHODS:Systematic review and meta-analysis of randomized controlled trials (RCTs) conducted in accordance with PRISMA guidelines, with a protocol registered in PROSPERO (CRD42025638656). SETTING/METHODS:Multicountry, multi-institutional hospital-based studies of patients undergoing cardiac surgery with CPB. PARTICIPANTS/METHODS:A total of 1133 patients from 16 RCTs comparing CPB with versus without intraoperative HA. INTERVENTIONS/METHODS:Intraoperative HA using sorbent-based devices (e.g., CytoSorb, oXiris, Jafron HA 380). MEASUREMENTS AND MAIN RESULT/RESULTS:Primary outcomes included AKI incidence, renal replacement therapy requirement, and mortality. Secondary outcomes included intensive care unit/hospital length of stay, postoperative delirium, stroke, sepsis, and reoperation. HA significantly reduced the incidence (RR 0.75; 95% CI 0.59-0.96; p = 0.020). No significant differences were observed for renal replacement therapy (RR 0.64; p = 0.58) or mortality (RR 0.96; p = 0.861). No significant effects were found for secondary outcomes. CONCLUSIONS:Intraoperative HA during CPB reduces the risk of AKI but does not significantly affect other major postoperative outcomes. Further studies are needed to determine its clinical relevance and optimal patient selection.

BACKGROUND AND AIMS/OBJECTIVE:Left ventricular assist devices (LVADs), including the HeartMate 3 (HM3), have improved outcomes in patients with advanced heart failure. Use of vitamin K antagonists (VKA) is mandated to reduce the risk of thrombotic events, but there is heterogeneity in management. Time in therapeutic range (TTR) is a crucial metric for assessing the quality of VKA management. The ARIES-HM3 trial demonstrated that aspirin can be safely omitted from the antithrombotic regimen, resulting in reduced bleeding without increased thrombosis. This pre-specified trial analysis explores the relationship of quality of VKA management assessed by TTR with haemocompatibility-related outcomes. METHODS:ARIES-HM3 was an international, randomized, double-blind, placebo-controlled study of aspirin (100 mg/day) or placebo (1:1) with VKA therapy in patients with de-novo HM3 placement. Participants were stratified into low TTR or high TTR groups based on median levels (n = 554). Primary endpoint success and secondary endpoint rates were stratified based on TTR groups. Bleeding rates at 12 months were estimated using an Andersen-Gill model with TTR as a single continuous variable, and multivariable regression analysis was performed. RESULTS:The percentage of patients with a TTR above or below the median of 56 was similar between the aspirin and placebo groups. More participants achieved primary endpoint success with TTR ≥56% (77% vs 66.9%, P = .01). Higher TTR was associated with lower bleeding rates at 12 months (26.4 vs 49.2 events per 100 participant-years; rate ratio 1.84, 95% confidence interval [CI] 1.37-2.53) without stroke increase (3.2 vs 2.8 events per 100 participant-years; rate ratio 0.88 [95% CI: 0.30-2.53]). No interaction was observed between the assigned treatment group and TTR. Modelling demonstrated a constant decrease in bleeding as a function of increasing TTR. Female sex and Black race were independent predictors of low TTR (odds ratio: 1.70 [95% CI: 1.12-2.57]; 1.62 [95% CI: 1.11-2.35], respectively), with more frequent INRs below the therapeutic range. Multivariable modelling identified age ≥65 years, aspirin use, TTR <56%, and blood urea nitrogen ≥30 mg/dL as predictors of non-surgical bleeding. CONCLUSIONS:The quality of VKA management as measured by TTR correlates with the occurrence of non-surgical bleeding in patients with the HM3 LVAD, with a lower TTR associated with an increased bleeding risk. These data provide new clinical direction to define a benchmark TTR to achieve further mitigation of residual risk of bleeding and enhance haemocompatibility with the HM3 LVAD.

BACKGROUND:Cardiogenic shock (CS) can be complicated by severe valvular heart disease (VHD). We analyzed cardiac intensive care unit (CICU) admissions according to VHD status. METHODS AND RESULTS/RESULTS:The Critical Care Cardiology Trials Network is a multicenter network of tertiary CICUs. Centers contributed data from consecutive admissions during 2-month annual snapshots from 2017-2023. CS admissions were classified as having CS attributed to VHD, CS with noncausative VHD or CS without severe VHD. Demographics and therapies were compared. Unadjusted and adjusted odds ratios for in-hospital mortality were calculated. We analyzed 5242 admissions with CS (4.1% attributed to VHD, 18.8% with noncausative VHD, 77.1% without severe VHD). Mitral regurgitation (32.1%) and aortic stenosis (27.9%) were the most common pathologies in CS attributed to VHD. Admissions with CS attributed to VHD more commonly had LVEF ≥ 40% on admission (present in 62.8%, 22.6% and 15.1%, respectively; P < 0.001). Valve intervention was performed in 32.1% of those with CS attributed to VHD. Unadjusted in-hospital mortality in admissions with CS attributed to VHD was 40.0%, compared to 33.4% and 30.3% in the other groups. CONCLUSIONS:VHD is the underlying cause of CS in a minority of CICU admissions but is associated with high in-hospital mortality rates.

BACKGROUND/UNASSIGNED:The Society for Cardiovascular Angiography & Intervention (SCAI) SHOCK stages classification schema risk-stratifies patients with cardiogenic shock (CS). The updated 2022 SCAI SHOCK stages removed the use of respiratory support, either noninvasive (NIV) or invasive mechanical ventilation (IMV), as a criterion. We sought to investigate the impact of receiving respiratory support on in-hospital mortality for patients with CS stratified by SCAI SHOCK stages. METHODS/UNASSIGNED:Utilizing a nationally representative database, adults aged ≥18 years admitted from 2015 to 2023 with a diagnosis of CS were used to assess for the association between respiratory support, either NIV or IMV, on the first day of admission, with in-hospital mortality stratified by SCAI SHOCK stages B through E. We utilized inverse probability treatment weighting, adjusting for demographic characteristics, comorbidities, hospital characteristics, and vasoactive/mechanical circulatory support. RESULTS/UNASSIGNED:We identified 317,325 patients with CS, including 2.4%, 39.0%, 34.2%, and 24.5% with SCAI stages B through E, respectively. Respiratory support was utilized in 38.0% (n = 120,594) of patients, with 5.4% receiving NIV, 33.8% receiving IMV, and 1.1% receiving both on the first day of admission. After inverse probability treatment weighting, respiratory support use remained associated with an increased mortality overall (weighted mean mortality increase of 18.3%; 95% CI, 17.9%-18.7%), when stratified by each SCAI SHOCK stage and in several key sensitivity analyses. CONCLUSIONS/UNASSIGNED:Compared with patients not receiving respiratory support, the use of respiratory support was associated with an increased mortality for each SCAI stage of CS and could be a simple, easily identifiable CS risk modifier.

BACKGROUND:The ARIES-HM3 (Antiplatelet Removal and Hemocompatibility Events With the HeartMate 3 Pump) trial demonstrated safety and decreased bleeding in eliminating aspirin from the antithrombotic regimen of patients implanted with a HM3 left ventricular assist device (LVAD). Whether pharmacologic therapies impact hemocompatibility-related adverse events (HRAEs) remains uncertain. OBJECTIVES/OBJECTIVE:In this trial analysis, the authors investigated associations between pharmacologic therapy and hemocompatibility outcomes. METHODS:Among 547 of 589 randomized patients who were discharged, non-inotrope-dependent, and completed 1-month of follow-up, the study explored the influence of pharmacotherapy (renin-angiotensin-aldosterone system [RAAS] inhibitors, heart failure [HF]-related and other cardiovascular drugs) on blood pressure control and on survival free of major nonsurgical HRAE (stroke, pump thrombosis, bleeding, and arterial thromboembolism) at 12 months. RESULTS:In 547 eligible patients, 65% received RAAS inhibitors, 89% received other HF-related therapy, and 82% received another cardiovascular drug at 1 month. No statistically significant interaction between RAAS inhibitors (P = 0.08), other HF-related therapies (P = 0.65), or other cardiovascular drugs (P = 0.92) on aspirin use and primary endpoint success was observed. Patients receiving RAAS inhibitors at 1 month had greater primary endpoint success (78.9% vs 69.3%, HR: 0.61 [95% CI: 0.37-1.01]; P = 0.14). Other HF-related therapies and cardiovascular drugs were not associated with primary event success either on or off prescription (HF-related therapy: 75.4% vs 76.7%; other cardiovascular drugs: 74.3% vs 81.3%). Pharmacologic therapy did not have a significant interaction with blood pressure control (RAAS inhibitors: P = 0.69; other HF-related therapy: P = 0.40). CONCLUSIONS:Background pharmacologic therapy did not modify the effect of aspirin on HRAE; however, the use of a RAAS inhibitor was independently associated with a reduction in HRAE. These exploratory observations may potentially point to opportunity for enhancing hemocompatibility in patients receiving LVAD therapy. (Antiplatelet Removal and Hemocompatibility Events With the HeartMate 3 Pump [ARIES-HM3]; NCT04069156).