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• Atria make both active and passive contributions throughout the cardiac cycle. • Atrial cardiomyopathy is gaining recognition in various cardiac conditions and is associated with worse prognosis. • Alterations in atrial mechanics are associated with incident heart failure and atrial fibrillation. • Atrial interventions may have adverse subclinical effects on atrial mechanics, which could ultimately result in overt clinical symptoms. • Standardized assessment of atrial mechanics following atrial interventions might allow early detection and prevention of irreversible atrial remodeling. Our comprehension of atrial mechanics, atrial cardiomyopathy and their clinical implications across various cardiovascular conditions has advanced significantly. Atrial interventions can have differing effects on atrial mechanics. With the rapid increase in the use of atrial interventions, it is crucial for investigators and clinicians to acknowledge the potential adverse effects of these interventions on atrial mechanics that might not be clinically significant at the time of interventions. Recognizing the preclinical stage of atrial maladaptation might enable early interventions before the development of irreversible atrial remodeling and clinical manifestation. We review normal atrial function and mechanics, and atrial cardiomyopathy in select cardiovascular conditions. We also summarize and discuss the current evidence of the impact of various atrial interventions on atrial function and mechanics. [Display omitted] [ABSTRACT FROM AUTHOR]

Left ventricular assist device therapy for advanced heart failure is contraindicated if a patient lives in an unsafe environment and recent guidelines declare that "legal history is pertinent for determining personal constraints or financial responsibilities due to parole requirements, pending charges, and possible imprisonment," implying that incarceration would be a contraindication. International guidelines and precedent in the United States establish that medical care for incarcerated persons should match access in the community. We present a case example and practical considerations for advanced heart failure programs faced with the challenge of partnering with patients with heart failure who may be incarcerated and their correctional health systems in the care of their chronic condition. We encourage the heart failure community to not let incarceration be a contraindication to left ventricular assist device therapy. [ABSTRACT FROM AUTHOR]

In HF patients, clinical congestion assessment is a cardinal sign in diagnosing and adapting therapeutic intensity but is subjective and considered insensitive. Objective non-invasive assessment of congestion would provide considerable support for early HF treatment and prevention of hospitalization for acute decompensation. A novel optical Molecular Chemical Imaging (MCI) device was used to collect reflected light from the skin and quantify the sub-cutaneous water content based on reflected wave-length modification using a short wave infrared (SWIR) device. To provide a highly acurate reference method we compared SWIR to MRI assessment of tissue water content using a 6-Point Dixon method (Liver Lab, Siemens Healthineers, Erlangen, Germany) in 12 hospitalized HF patients. The calve imaging region locations were co-located for SWIR and MRI using the patella as reference point and tests were performed within 4 hours. 4 independent Water Fraction (WF) values were measured within the calve area for each patient and quantified as a percentage. Accuracy was calculated by comparing predicted value of SWIR to the value measured by MRI within an MRI error tolerance (0.11±0.02). 12 subjects (age 72±12.8, 6 women) presented with no edema in 5 and mild edema in 7. Five of the 48 (10%) limb measurements were excluded due to inadequate imaging. In 39 of 43 coupled WF measurements the SWIR results were within the MRI error range (accuracy 90.7%). Correlation between WF values obtained by SWIR and MRI was excellent (R2 0.8), as shown in Figure 1. Despite the frequent absence of clinical edema, quantification of WF by MRI or SWIR demonstrated a broad range of congestion levels, unsuspected clinically. In patients hospitalized for HF, SWIR assessment of subcutaneous water fraction was feasible and highly correlated with measurement by MRI. There was a broader range of congestion than was appreciated clinically. A larger experience is warranted to expand the accuracy assessment with all types of skin and broader levels of clinical edema. This early experience suggests that optical non-invasive congestion assessment has the potential to improve objective evaluation of congestion in patients with HF clinical management, an essential element in improving clinical outcomes. [ABSTRACT FROM AUTHOR]

Background HAS-BLED and CHA 2 DS 2 -VASc scores predict bleeding in patients on anticoagulation and thromboembolic (TE) risk in patients with atrial fibrillation, respectively. We hypothesized that these scores would be predictive of bleeding and TE complications following continuous-flow ventricular assist device (CF-VAD) implantation. Methods and Results Baseline HAS-BLED and CHA 2 DS 2 -VASc scores were retrospectively determined for 173 consecutive patients who underwent HeartMate II CF-VAD implantation at a single center from 2005 to 2011. Forty-three patients had bleeding (24.9%) and 22 had TE (12.7%) events over a 290 patient-year follow-up period. The mean ± SD HAS-BLED scores were 2.7 ± 1.0 and 1.9 ± 1.1 ( P < .0001) in patients with and without bleeding, respectively. The CHA 2 DS 2 -VASc scores were 3.6 ± 1.4 and 2.9 ± 1.5 ( P = .03) in patients with and without TE events, respectively. A HAS-BLED score of ≥3 was associated with a significantly higher risk of bleeding events compared with a score of <3 (42% vs 15%, respectively; hazard ratio [HR] 3.40, 95% confidence interval [CI] 1.82–6.32; P < .001). A CHA 2 DS 2 -VASc score of ≥3 was associated with a higher risk of TE events compared with a score of <3 (18% vs 4%, respectively; HR 4.02, 95% CI 1.19–13.6; P = .025). Conclusions Baseline HAS-BLED and CHA 2 DS 2 -VASc scores of ≥3 conferred significantly higher risks of bleeding and TE, respectively, following HeartMate II implantation. [ABSTRACT FROM AUTHOR]

Background: Published data on mechanical circulatory support for elderly patients in continuous flow devices are sparse and suggest relatively poor survival. This study investigated whether LVADs can be implanted in selected patients over the age of 65 years with acceptable survival compared with published outcomes. Methods and Results: A single-center retrospective analysis was conducted in 64 consecutive patients ≥65 years of age implanted with a continuous-flow left ventricular assist device (CF-LVAD) as either bridge to transplantation or destination therapy from August 2005 to January 2012. Baseline laboratory and hemodynamic characteristics and follow-up data were obtained. Median survival was 1,090 days. Survival was 85%, 74%, 55%, and 45% at 6 months and 1, 2, and 3 years, respectively. Our cohort had a baseline mean Seattle Heart Failure Model (SHFM) score of 2.6 ≥ 0.9. Observed survival was significantly better than SHFM-predicted medical survival. Stratification by age subsets, renal function, SHFM, implantation intention, or etiology did not reveal significant differences in survival. The most common cause of death was sepsis and nonlethalcomplication was bleeding. Conclusions: Our experience with patients over the age of 65 receiving CF-LVADs suggests that this group demonstrates excellent survival. Further research is needed to discern the specific criteria for risk stratification for LVAD support in the elderly. [ABSTRACT FROM AUTHOR]

Abstract: Despite substantial improvements in treatment for chronic heart failure, morbidity and mortality for acute decompensated heart failure (ADHF) remain high. Treatment of ADHF is focused on controlling symptoms rather than improving long-term outcomes. The vasodilators nitroglycerin (NTG) and sodium nitroprusside (SNP) have been used in ADHF for decades, but, since the development of nesiritide 10 years ago, interest in new vasodilators has grown. Therapies that improve not only hemodynamics and symptoms but also long-term outcomes are in high demand, and numerous new vasodilatory agents have been investigated, including various natriuretic peptides, soluble guanylyl cyclase agents, renin-angiotensin-aldosterone system–modifying agents, and others. A review of the literature shows that few of them rise to the challenge set by NTG and SNP. [Copyright &y& Elsevier]

The allocation system for heart transplantation changed in the United States on October 18, 2018. In this analysis, we report donor quality metrics by UNOS status for patients transplanted under the new allocation system. We suspect higher quality (male, younger, less under-sized) donors will be allocated to patients with the highest acuity UNOS status recipients. Adults (18 years and older) who underwent first-time heart transplantation were identified from the United Network for Organ Sharing (UNOS) registry after October 18, 2018. Donor characteristics by UNOS recipient status then were compared with one-way ANOVA and chi-squared tests, where appropriate. To determine the percent of donors that were under-sized, predicted total ventricular mass for each donors and recipient pair was calculated utilizing previously published models based on age, sex, height, and weight. Under-sizing was defined as a calculated donor mass of more than 10% under the recipient cardiac mass, based on previously reported ideal ranges. The analysis included 1,817 patients (Status 1: 141, Status 2: 807, Status 3: 478, Status 4: 319, Status 5: 72). Statistically significant differences were observed across the UNOS status groups, with higher acuity status recipients receiving younger donors with less donor hypertension (Table). Higher acuity status recipients were less likely to receive female donors into male recipients or to be under-sized (Status 1 & 2: 18.7% under-sized vs. Status 3, 4, & 5: 23.8% under-sized, p=0.007). Ischemic times were longer for Status 1 and 2 recipients. Donor alcohol and cocaine use were similar across UNOS statuses. Initial analysis reveals that heart transplant recipients with the highest acuity UNOS status are receiving donor hearts with more favorable donor characteristics although with longer ischemic times. More detailed analysis of the donor characteristics and longer follow-up time will be need to further quantify and assess the impact of this measurable variation in donor quality on post-transplant outcomes. [ABSTRACT FROM AUTHOR]

Acute decompensated heart failure (ADHF) is associated with a high rate of readmissions and mortality. Remote dielectric sensing (ReDS) fluid monitoring provides an accurate tool for non-invasive measurement of absolute lung fluid content, providing actionable information and a new tool for managing HF. The SMILE trial was a prospective, multicenter, randomized clinical trial testing the hypothesis that post-discharge HF management guided by frequent in-home ReDS assessment is superior to usual care. Patients with a current hospitalization for ADHF, regardless of the LVEF, were enrolled in 43 US centers. Subjects randomized to the treatment arm were discharged home with the ReDS fluid monitor system and managed using ReDS measurements, according to protocol-defined algorithms. Control patients received usual care, without ReDS. The primary endpoint was recurrent (cumulative) ADHF hospitalizations, analyzed using the Andersen-Gill model with treatment group as the only covariate. Patients were followed for up to 9 months, until the last patient enrolled reached 3 months of follow-up. Between October 2015 and October 2017, 268 patients were randomized - 135 to treatment and 133 to control - and followed for 6.1±3.4 months. Patients were aged 68±12 years; 30% were women and 29% had LVEF≥40%. Pre-specified analysis of the per-protocol cohort demonstrated 21 readmissions in 15 ReDS patients compared to 43 readmissions in 34 control patients (HR 0.52, 95% CI [0.31-0.87], P=0.01) or a 48% readmissions reduction (Figure). Subgroup analysis by LVEF < or ≥40% showed similar reductions in ADHF readmissions (RRR 50%, P=0.03 and 46%, P=NS, respectively), with ReDS-guided HF management. Number of days lost to ADHF hospitalization was lower (1.37 vs. 2.62 days, 48% reduction, P=0.006) and time from discharge to first ADHF readmission was longer (HR 0.45, 95% CI [0.25-0.83], P=0.01), for ReDS-guided management. There was no significant difference in mortality between groups. The SMILE trial demonstrates a substantial reduction in recurrent ADHF hospitalizations and improvement in other outcome measures in recently discharged ADHF patients managed using daily ReDS assessment of absolute lung fluid content. [ABSTRACT FROM AUTHOR]