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A 54-year-old man with chronic obstructive pulmonary disease (COPD) presented with three days of chest pain, dyspnea on exertion, and orthopnea. Physical examination revealed jugular venous distention and lower extremity edema. Cardiac biomarkers were elevated. The differential diagnosis for the clinical presentation included: acute coronary syndrome, and type II myocardial infarction or myocardial injury due to acute decompensated heart failure. External records demonstrated recurrent admissions for similar signs and symptoms, with negative coronary angiogram. Shortly after admission, the patient developed acute cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation. Echocardiogram revealed biventricular failure and a possible mitral valve vegetation. The differential diagnosis was refined to include myocarditis (infectious and noninfectious causes), bacterial versus marantic endocarditis, and infiltrative cardiomyopathies. Transesophageal echocardiography revealed mass-like, bileaflet thickening of the mitral valve, not consistent with true vegetation. Infectious, rheumatologic, and hypercoagulable workups were negative. Given the lack of a unifying diagnosis, a right ventricular (RV) endomyocardial biopsy was pursued. This revealed myocardial necrosis and fibrosis, and a mural thrombus with extensive eosinophils. The primary data was then revisited, which revealed history of peripheral eosinophilia that was intermittently suppressed by steroids given for COPD. Cardiac magnetic resonance imaging (MRI) demonstrated diffuse biventricular subendocardial late gadolinium enhancement and RV thrombi. Evaluation for underlying causes of eosinophilia was negative leading to the diagnosis of Loeffler’s endocarditis due to idiopathic hypereosinophilic syndrome. This case demonstrates: (1) the important role of cardiac MRI in the evaluation of both unexplained myocardial injury and new cardiomyopathy, (2) a rare case of Loeffler’s endocarditis requiring mechanical circulatory support, and (3) the consequences of both availability bias and failure to fully “unpack” the primary diagnostic data, which rendered the true etiology of the patient’s cardiogenic shock “hidden in plain sight.”

Mechanical assist devices have emerged as an established therapeutic option for patients with end-stage heart failure. Predicting which patients are unlikely to benefit from continuous flow left ventricular assist device (cf-LVAD) treatment is crucial for the identification of appropriate patients while excluding those considered futile. Previously developed scoring systems are limited to prior eras of device and medical support or restricted to specific devices. Methods: We performed a retrospective analysis of all patients implanted with a cf-LVAD (Heartmate II or HVAD) at our institution between 2005 and 2014. From all plausible pre-operative covariates, we performed univariate Cox regression analysis for covariates affecting the odds of 1yr post implantation survival (p Results: A total of 204 patients (male 78%; mean age 57+15, mean follow up 465+486 days). After stepwise selection for variables that increased predictive power, a final optimized model was identified (Figure). One yr survival was significantly lower in patients with higher risk score (HR 2.48, p= Conclusion: We present a novel risk score and its validation for prediction of long-term survival in patients on cf-LVAD support. This score may prove useful for patient selection and identification of patients requiring adjuvant therapies

We thank Drs Psaty, Shah, and Gottdiener for their interest in our article. They expressed concern with our study methodology and, more specifically, our patient population. The Penn Heart Failure Study cohort was composed of patients who had heart failure for an average of 6 years before recruitment at 1 of 3 tertiary care centers.1 As the authors note, this delay in study enrollment selects for patients who survived early disease, but are sufficiently ill to require referral to a tertiary care center. This may introduce bias in the estimation of prognosis, and precludes analysis of …

Background— We hypothesized that patients with heart failure (HF) who recover left ventricular function (HF-Recovered) have a distinct clinical phenotype, biology, and prognosis compared with patients with HF with reduced ejection fraction (HF-REF) and those with HF with preserved ejection fraction (HF-PEF). Methods and Results— The Penn Heart Failure Study (PHFS) is a prospective cohort of 1821 chronic HF patients recruited from tertiary HF clinics. Participants were divided into 3 categories based on echocardiograms: HF-REF if EF was P P =0.013) compared with HF-Recovered patients. The unadjusted hazard ratio for cardiac hospitalization in HF-REF patients was 2.0 (95% confidence interval, 1.5–2.7; P P =0.15) compared with HF-Recovered patients. Results were similar in adjusted models. Conclusions— HF-Recovered is associated with a better biomarker profile and event-free survival than HF-REF and HF-PEF. However, these patients still have abnormalities in biomarkers and experience a significant number of HF hospitalizations, suggesting persistent HF risk.