Faculty Bibliography

OBJECTIVES/OBJECTIVE:To understand how patients make decisions regarding a left ventricular assist device (LVAD). DESIGN/METHODS:A qualitative multiple case study design was used to explore the context and influence of individuals regarding patients' decision-making processes through: 1) detailed, in-depth interviews of those mostly involved in the patient's decision and 2) pertinent data including observations, medical records, educational information and physical artifacts. Data clusters and patterns of co-occurring codes were examined using thematic analysis. MAIN OUTCOME MEASURES/METHODS:Themes were extrapolated from individual case summaries to provide an in-depth analysis of each case and a cross-case analysis across the multiple cases. The predominant theme, consistent with other studies, was the salience of survival. FINDINGS/RESULTS:This case study approach revealed new themes beyond those of prior studies. Patients considered: 1) self-care management for patients without a caregiver, 2) acceptability and future expectations of the LVAD and 3) the role of nurses in eliciting patients' fears, values and preferences. CONCLUSION/CONCLUSIONS:The patients' decision-making processes regarding an LVAD involve a cost-benefit analysis of the anticipated needs and consequences of the LVAD. Acceptability of the device is relevant to clinical practice and public policy. Nurses have a unique role in seeking patients' concerns, an essential component of shared decision-making.

Purpose: Heart transplantation (HTx) from hepatitis C virus (HCV) positive donors to HCV negative recipients may reduce waitlist time and increase access to viable organs. Direct acting antivirals (DAAs) are highly successful at curing HCV infection, but the effect of DAAs on the pharmacokinetics of calcineurin inhibitors is largely unknown. We describe the effect on tacrolimus dosage requirements in recipients of HCV viremic donors. Method(s): We retrospectively reviewed HCV negative HTx patients who received a HCV positive organ. All patients received an 8 week course of glecaprevir-pibrentasvir (GP) for HCV treatment and were on standard triple immunosuppression therapy. Patients receiving concomitant medications that affect tacrolimus metabolism were excluded. All tacrolimus dosages and trough levels were collected from the time of initiation post-HTx until 1 month after completion of GP treatment. Tacrolimus dose normalized concentrations using the concentration:dose ration (ng/mL:mg/kg) were compared before, during, and after GP treatment. Result(s): Seven HTx recipients were included in the analysis. Tacrolimus dose normalized concentrations were 124.8, 163.4, and 196.7 (ng/mL)/(mg/kg/d) before, during and after GP treatment, respectively (Figure 1). Tacrolimus dosage requirements did not differ during GP treatment as compared to before or after GP treatment. The percentage of tacrolimus trough levels within goal range and the incidence of supratherapeutic tacrolimus levels, was 51% vs. 41% and 4% vs. 0% during GP treatment as compared to after GP treatment. Conclusion(s): We did not find a difference in tacrolimus dosage requirements while receiving GP treatment as compared to before or after GP treatment; however, this study was limited by a small sample size. No empiric dosage adjustments can be recommended when initiating or discontinuing GP treatment at this time. Further data will be needed to strengthen these findings.

Introduction: Cardiogenic shock is associated with high in-hospital mortality rates regardless of etiology. Recently, there has been an increase in utilization of acute mechanical circulatory support (MCS) in patients with cardiogenic shock. Although there is no consensus as to the most appropriate device for any particular patient presentation, acute MCS devices have been widely adopted in institutions that favor an aggressive approach to cardiogenic shock. Establishment of an Adult ECMO Program at our institution has led to experience with additional acute MCS devices. The complexity of these clinical situations led to the creation of a multidisciplinary team, including a combination of cardiologists, surgeons, interventionalists, and intensivists, committed to treating these patients. As an early ECMO Program and Cardiogenic Shock Team, we sought to review our early experience with acute MCS for cardiogenic shock to define our baseline strategies and outcomes in this patient population. Materials and Methods: We completed a retrospective review of cardiogenic shock patients who were treated with acute MCS by Fiscal Year (September 1 to August 31) beginning with Fiscal Year (FY) 2014. We reviewed implant volume by device, including temporary surgical ventricular assist device (VAD), percutaneous and surgical Impella, percutaneous RVADs, and veno-arterial Extracorporeal Membrane Oxygenation (VA-ECMO). Data collected included etiology of shock, indication for device implantation, type of support offered, length of support, and outcome of support. For each category of device, we also reviewed our outcomes by mirroring the established ELSO benchmarks of "Survival from ECMO" and "Survival to Discharge." Results: We found a steady increase in the use of acute MCS for treatment of cardiogenic shock from FY 2014 to FY 2018. From FY 2014 to 2015 there was an increase from zero to 18 implants. The following year (FY 2016) revealed a 100% increase, with a total of 36 implants. The volume increased more slowly (16%/year) the following two years (FY 2017, FY 2018) with 43 and 48 implants, respectively. Overall outcome assessment revealed that 68% of patients survived acute MCS and 53% of patients survived to hospital discharge with an increased survival to discharge in the last fiscal year to 62%. Conclusion: Creation of an Adult ECMO Program and a multidisciplinary Cardiogenic Shock Team correlated with an increase in the number of patients supported with acute MCS. As the team gains experience with these patients and the devices available to support them, we expect the outcomes to continue to improve. Patient selection, surgical approaches and techniques, standardizing medical therapy, and managing and reducing complications will give these patients the best opportunity to survive

BACKGROUND: Interventions to reduce readmissions following acute heart failure hospitalization require early identification of patients. The purpose of this study was to develop and test accuracies of various approaches to identify patients with acute decompensated heart failure (ADHF) using data derived from the electronic health record. METHODS AND RESULTS: We included 37,229 hospitalizations of adult patients at a single hospital in 2013-2015. We developed four algorithms to identify hospitalization with a principal discharge diagnosis of ADHF: 1) presence of one of three clinical characteristics; 2) logistic regression of 31 structured data elements; 3) machine learning with unstructured data; 4) machine learning with both structured and unstructured data. In data validation, Algorithm 1 had a sensitivity of 0.98 and positive predictive value (PPV) of 0.14 for ADHF. Algorithm 2 had an area under the receiver operating characteristic curve (AUC) of 0.96, while both machine learning algorithms had AUCs of 0.99. Based on a brief survey of three providers who perform chart review for ADHF, we estimated providers spent 8.6 minutes per chart review; using this this parameter, we estimated providers would spend 61.4, 57.3, 28.7, and 25.3 minutes on secondary chart review for each case of ADHF if initial screening was done with algorithms 1, 2, 3, and 4, respectively. CONCLUSION: Machine learning algorithms with unstructured notes had best performance for identification of ADHF and can improve provider efficiency for delivery of quality improvement interventions.

BACKGROUND/OBJECTIVES: Frailty, characterized by low physiological reserves, is strongly associated with vulnerability to adverse outcomes. Features of frailty overlap with those of advanced heart failure, making a distinction between them difficult. We sought to determine whether implantation of a left ventricular assist device (LVAD) would decrease frailty. DESIGN: Prospective, cohort study. SETTING: Five academic medical centers. PARTICIPANTS: Frail individuals (N = 29; mean age 70.6 +/- 5.5, 72.4% male). MEASUREMENTS: Frailty, defined as having 3 or more of the Fried frailty criteria, was assessed before LVAD implantation and 1, 3, and 6 months after implantation. Other domains assessed included quality of life, using the Kansas City Cardiomyopathy Questionnaire; mood, using the Patient Health Questionnaire; and cognitive function, using the Trail-Making Test Part B. RESULTS: After 6 months, three subjects had died, and one had undergone a heart transplant; of 19 subjects with serial frailty measures, the average number of frailty criteria decreased from 3.9 +/- 0.9 at baseline to 2.8 +/- 1.4 at 6 months (P = .003). Improvements were observed after 3 to 6 months of LVAD support, although 10 (52.6%) participants still had 3 or more Fried criteria, and all subjects had at least one at 6 months. Changes in frailty were associated with improvement in QOL but not with changes in mood or cognition. Higher estimated glomerular filtration rate at baseline was independently associated with a decrease in frailty. CONCLUSION: Frailty decreased in approximately half of older adults with advanced heart failure after 6 months of LVAD support. Strategies to enhance frailty reversal in this population are worthy of additional study.

BACKGROUND: Pulmonary artery intimal spindle cell sarcomas are rare and carry with them a poor prognosis and high rate of recurrence. In extremely rare cases, this tumor can infiltrate the pulmonic valve and manifest as adult-onset pulmonic stenosis. CASE PRESENTATION: We report an unusual case of a patient with symptomatic, adult-onset severe pulmonic stenosis who was referred for possible balloon valvuloplasty but was subsequently found to have pulmonary artery intimal sarcoma infiltrating the pulmonary valve leading to progressive exertional dyspnea. CONCLUSION: The presence of adult-onset pulmonic stenosis should prompt the clinician to investigate further as most cases of pulmonic stenosis are congenital in nature and present early in life. Careful diagnostic evaluation in concert with multimodal imaging should take place to arrive at the correct and challenging diagnosis of sarcoma-induced adult-onset severe pulmonic stenosis. Given the poor prognosis and rapid progression of disease, early diagnosis is crucial.

Purpose of Review Advances in medical therapy have resulted in a growing population of older adults with advanced heart failure. Frailty is a clinical syndrome that increases in prevalence with age and is highly prevalent in patients with heart failure. This paper reviews the complex relationship between frailty and advanced systolic heart failure in older adults, including the potential for reversal of frailty following advanced cardiac interventions. Recent Findings Frailty is predictive of adverse outcomes, including rehospitalization and mortality, in heart failure patients. Several small studies have shown that mechanical circulatory support can modify, and possibly reverse, functional impairments and the pathophysiologic changes associated with heart failure-related frailty. Summary Frailty is highly prevalent in patients with advanced heart failure and is a powerful prognostic marker. Routine frailty assessment could allow clinicians to define optimal patient-centered care strategies for older adult patients with advanced heart failure.