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Patients with continuous flow left ventricular assist devices (CF-LVAD) typically have a narrow pulse pressure. This may pose a challenge for transcutaneous automated pulse oximeter devices to accurately measure arterial blood saturation. This study aimed to assess their accuracy in a CF-LVAD population by comparing pulse oximetry readings to invasive arterial blood gas (ABG) measurements. A total of eighteen patients with a CF-LVAD were identified using chart review at the University of Minnesota and Minneapolis Heart Institute. All, except one patient were implanted with a HeartMate III device (Abbott Laboratories, Minneapolis, MN). Non-invasively assessed oxygen saturation was compared to simultaneously obtained arterial blood oxygen saturation. Two patients were receiving mechanical ventilation, one received BiPAP support, and 15 patients were either breathing room air or receiving supplemental oxygen by nasal cannula. A non-invasive pulse oximeter read was obtained on every patient. There was a moderate correlation between the invasively and non-invasively obtained oxygen saturation values as shown in Figure 1 (R2=0.624). Waveform quality, as assessed by the treating physician, qualified as good or acceptable in 16 cases and as poor for 2 patients. Data points for these 2 patients are marked in red in Figure 1. Despite a narrow pulse pressure in patients with CF-LVAD, non-invasive pulse oximetry provided a reliable assessment of arterial blood saturation when compared to the gold standard ABG measurement. This finding presents an opportunity to conduct future studies in this patient population in which continuous monitoring of oxygen saturation may be necessary, such as evaluation for obstructive sleep apnea. [ABSTRACT FROM AUTHOR]

While heart failure (HF) is a leading cause of mortality and readmissions, only a small percentage of patients are optimized on guideline-directed medical therapy (GDMT). We developed a multidisciplinary HF clinic to optimize medications, provide education and resources and screen for medical co-morbidities in HF patients. A multidisciplinary clinic composed of Advanced Practice Providers (APPs), pharmacist, nutritionists and nurses was developed and targeted patients with a 30-day HF readmission, ≥ 2 HF-related hospitalizations in last 12 months or new HF diagnosis. The OPTIMIZE clinic consisted of a total of 6 visits approximately two weeks apart seeing an APP at each visit along with pharmacy and nutrition evaluation. Echocardiographic, 6-minute walk, and health related quality of life (EQ5D) outcomes were measured at baseline and at the end of the 12 weeks. A total of 62 patients with heart failure with reduced ejection fraction (HFrEF) completed OPTIMIZE clinic over an average of 11.6 weeks. Patients were primarily white (62.3%) males (56.5%) with an average age of 59.1 (±15.3) years. HF etiology was primarily non-ischemic (65%) and patients had typical cardiac comorbidities - hypertension 54%, hyperlipidemia 33%, diabetes 23%, sleep apnea 15%, and chronic kidney disease 24%. Completion of OPTIMIZE clinic resulted in significant improvements in 6-minute walk distance, left ventricular ejection fraction (LVEF), and patient reported quality of life measures as assessed by the EQ5D along with significant reductions in brain natriuretic peptide (BNP) and left ventricular internal diameter in diastole (LVIDd) (Figure 1a). We also saw improved utilization of GDMT with completion of the OPTIMIZE clinic (Figure 1b). During the course of the clinic, only 7 (11%) patients were admitted for CHF exacerbation and 44 referrals were made to various other cardiology or internal medicine subspecialities, the most common being sleep clinic (14 referrals). A total of 13 (21%) patients had enough improvement in LVEF on GDMT as a result of this clinic that they no longer met criteria for implantable cardioverter defibrillator implantation. Successful implementation of a multidisciplinary HF optimization clinic can help improve GDMT utilization, HF education, comorbidity recognition, and markers of HF severity. An OPTIMIZE clinic model can be considered in other centers as a way to increase GDMT optimization and improve clinical and functional markers of HF. [ABSTRACT FROM AUTHOR]

Digoxin use within the heart failure population remains controversial, as studies have suggested increased arrhythmia risk and lower survival. Despite decades of use in heart failure, little is known regarding digoxin utilization post-left ventricular assist device (LVAD). We aimed to evaluate if digoxin use impacts overall survival or incidence of right ventricular (RV) failure after LVAD implantation. Analysis was performed on 320 patients who underwent LVAD implantation from 2004-2017 and survived to hospital discharge. Patients were divided into groups based on digoxin utilization at discharge following LVAD placement. RV failure was defined as a composite of central venous pressure > 16mmHg or need for inotropic medication post-discharge or admission for intravenous diuretic therapy. Survival was assessed via Kaplan-Meier method and compared via log-rank test. Between group differences were assessed using independent sample t-tests and Fisher's exact tests. The cohort (n=320) had an average age of 56.2 (±13) years and contained 70 (21.9%) female patients. A majority ((n=129 (60%)) were implanted as destination therapy with 112 (35%) patients prescribed digoxin at the time of discharge (See Figure 1). Patients on digoxin were more likely to have a non-ischemic cardiomyopathy (p=0.002), had higher pulmonary vascular resistance (PVR) (p=0.03), and had larger left ventricular (p<0.001) and right ventricular (p<0.001) diastolic diameters prior to implantation compared to those not discharged on digoxin (See Figure 1). Despite higher PVR and biventricular dilation in patients discharged on digoxin, there was no difference in overall survival between the two groups at 2 years post-implantation (Figure 2). A trend suggesting reduced incidence of RV failure in the first 6 months post-LVAD implantation with digoxin use was present (p=0.11). Despite concerns about its continued use in different heart failure populations, overall survival was similar in LVAD patients with and without digoxin use at the time of initial discharge. A trend of reduced RV failure was present with digoxin use. Further studies are needed to fully elucidate the optimal patient population that may benefit from digoxin use following LVAD implantation. [ABSTRACT FROM AUTHOR]

Pulmonary hypertension (PH) in patients with COPD is associated with an increase in the risk of COPD exacerbation, increased hospitalization and worse survival in this patient population. The majority of patients with COPD have a mild degree of pulmonary hypertension (with mean pulmonary artery pressure, mPAP < 35 mmHg), however higher degrees of PH, also known as out-of-proportion PH, are seen in less that 5% of patients and signal the development of an intrinsic pulmonary vascular pathology. This study evaluates the role of selexipag in treatment of out of proportion pulmonary hypertension in COPD patients. Selexipag improves functional capacity in COPD patients with out of proportion pulmonary hypertension. We reviewed the medical records of COPD patients who were started on selexipag for out of proportion pulmonary hypertension. The patients were diagnosed with COPD according to their history, pulmonary function tests and chest imaging. All patients had a right heart catheterization done at baseline that showed pulmonary hypertension with mPAP ≥ 35 mmHg at rest. Six-minute walk test was done at baseline and repeated at 6 months (+/- 2 months) after starting selexipag. Out of the six patients included in this study, five patients showed improvement of 6-minute walk distance (from 512 feet to 681 feet, mean change 169 feet) while 1 patient worsened (from 1177 feet to 913 feet). In this case series of COPD patients with out of proportion pulmonary hypertension, the use of selexipag was associated with an improvement in functional status at 6 months. Larger size prospective studies are needed to confirm the findings. [ABSTRACT FROM AUTHOR]

Exercise-induced pulmonary hypertension (EiPH) can cause a significant deterioration in quality of life as well as a decrease in life expectancy. Additionally, EiPH may precede the development of manifest PH in a proportion of patients. In this study, we evaluated the effect of riociguat on the functional capacity of patients with EiPH. Riociguat improves 6-minute walk test in patients with exercise-induced pulmonary hypertension. We reviewed the medical records of patients who were started on riociguat for exercise induced pulmonary hypertension. All patients had a right heart catheterization done at baseline that showed normal pulmonary hemodynamics (mPAP < 20 mmHg and PVR < 3 Wood units) with an evidence of exercise induced pulmonary hypertension (mPAP >30 mmHg, PVR> 3 Wood units at maximum arm exercise). All patients had a baseline 6-minute walk test, and a repeat test at 6 months (+/− 2 months) after starting riociguat. Out of the nine patients included in this study, seven patients showed improvement of 6-minute walk distance (from 891 feet to 1197 feet, mean change 306 feet). One patient showed worsening of 6MWT (from 991 feet to 905 feet) and one patient did not show any significant change from baseline. In this case series of patients with exercise induced pulmonary hypertension, the use of riociguate was associated with an improvement in the functional status of patients with EiPH at 6 months. Larger size prospective studies are needed to confirm the findings. [ABSTRACT FROM AUTHOR]

A 63-year-old male with a history of coronary artery disease and severe aortic stenosis status post mechanical aortic valve replacement and coronary artery bypass presented with atypical chest pain and group B streptococcal bacteremia. His transesophageal echo (TEE) was read as negative for vegetations, and chest computed tomography (CT) was reportedly unremarkable. He was started on antibiotics, and coronary angiography showed severe triple-vessel disease, patent left internal mammary artery graft, and complete occlusion in all vein grafts. Percutaneous intervention with stenting of the left anterior descending and circumflex artery was performed. During the diagnostic angiography, nonselective contrast injection showed an anterior aortic root "pouch" (A, Online video 1), but since the CT was unremarkable, no further investigation was done. A month later, the patient presented with fatigue and persistent bacteremia. TEE showed a large circumferential hypoechoic space with radial strands around the sewing ring of the mechanical valve (B) along with new moderate perivalvular leak (C). A CT scan showed extensive perivalvular and para-aortic contrast collections extending from below the aortic annulus to mid-ascending aorta, consistent with abscesses/pseudoaneurysms (D, E). Both right and left coronary arteries were coursing through these abscesses/ pseudoaneurysms (E, arrows). The mechanical valve was sitting on the abscesses and appeared to be dehiscent (D). Retrospective review of the initial TEE (F) and CT (G) showed evidence of aortic root infection (arrows). The patient underwent aortic root repair and aortic valve replacement. An aortic root pathology specimen showed fibrous growth with calcification and focal acute and chronic inflammation. After a complicated hospital course, the patient was discharged to a rehabilitation facility. Meticulous evaluation with imaging and high index of suspicion is necessary when there is a question about infection in patients with prosthetic valves. [ABSTRACT FROM AUTHOR]