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Frailty and malnutrition in patients with heart failure are barriers to durable left ventricular assist device (D-LVAD) support and heart transplantation. Moreover, cachexia in patients with advanced heart failure carries a high mortality risk. There are no guidelines for these patients other than increased caloric intake and rehabilitation. Patients suffering from cardiac cachexia and heart failure may benefit from temporary, percutaneous assist device support to improve the underlying heart disease and reverse the catabolic state. We retrospectively reviewed patients from January 2017 to January 2022. All patients who received Impella support (5.0 or 5.5, Abiomed) before D-LVAD implantation were screened. Those who met the criteria for cardiac cachexia were included. Patient demographics, nutritional and biochemical markers, and survival data were collected. A total of 14 patients were included. The majority of patients were male (85.7%) with ischemic cardiomyopathy (64.3%). Caloric intake, physical strength, and ambulation improved. Prealbumin levels improved from a median of 13.7-18.0 mg/dl ( p < 0.006) while on Impella 5.0 or 5.5 support. All patients survived to discharge and the 6 month follow-up. In conclusion, use of the Impella device improves cardiogenic shock symptoms and, consequently, may improve cachexia status prior to D-LVAD implantation., (Copyright © ASAIO 2023.)

Background: This study assessed in-hospital outcomes of patients with chronic systolic, diastolic, or mixed heart failure (HF) undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR)., Methods: The Nationwide Inpatient Sample database was used to identify patients with aortic stenosis and chronic HF who underwent TAVR or SAVR between 2012 and 2015. Propensity score matching and multivariate logistic regression were used to determine outcome risk., Results: A cohort of 9,879 patients with systolic (27.2%), diastolic (52.2%), and mixed (20.6%) chronic HF were included. No statistically significant differences in hospital mortality were noted. Overall, patients with diastolic HF had the shortest hospital stays and lowest costs. Compared with patients with diastolic HF, the risk of acute myocardial infarction (TAVR odds ratio [OR], 1.95; 95% CI, 1.20-3.19; P = .008; SAVR OR, 1.38; 95% CI, 0.98-1.95; P = .067) and cardiogenic shock (TAVR OR, 2.15; 95% CI, 1.43-3.23; P < .001; SAVR OR, 1.89; 95% CI, 1.42-2.53; P ≤ .001) was higher in patients with systolic HF, whereas the risk of permanent pacemaker implantation (TAVR OR, 0.58; 95% CI, 0.45-0.76; P < .001; SAVR OR, 0.58; 95% CI, 0.40-0.84; P = .004) was lower following aortic valve procedures. In TAVR, the risk of acute deep vein thrombosis and kidney injury was higher, although not statistically significant, in patients with systolic HF than in those with diastolic HF., Conclusion: These outcomes suggest that chronic HF types do not incur statistically significant hospital mortality risk in patients undergoing TAVR or SAVR., (© 2023 by the Texas Heart® Institute, Houston.)

Objectives: To determine in-hospital outcomes and assess high-risk groups among chronic heart failure (CHF) patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR)., Design: A retrospective analysis of the Nationwide Inpatient Sample database from January 2012 to September 2015 was performed., Setting: Hospitals across the United States that offer TAVRs or SAVRs., Participants: Adults with a diagnosis of CHF and AS., Interventions: The patients underwent either TAVR or SAVR., Measurements and Main Results: Totals of 5,871 and 4,008 CHF patients underwent TAVR and SAVR, respectively. TAVR patients were significantly older, more were female, and had a higher comorbidity burden. No significant differences in in-hospital mortality were noted between TAVR and SAVR. However, mean length of stay was significantly longer by 3.5 days in the SAVR group, as was the mean total cost. With the exception of complete heart block, permanent pacemaker implantation, and vascular complications, the majority of postoperative events were higher among the SAVR group. Multivariate regression analysis identified postoperative cardiac, respiratory and renal complications as significant predictors of in-hospital mortality for both groups. Additionally, age ≥75 years and vascular complications were significant predictors of mortality for patients undergoing TAVR., Conclusions: Among CHF patients with symptomatic AS, TAVR had similar in-hospital mortality rate compared with SAVR despite higher comorbidity burden. TAVR patients are at a lower risk of cardiovascular, respiratory, and renal complications and might lead to reduced length of hospital stay and cost. Hence, TAVR may be a safer option in this population., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Yearly rate and mean patient age of left ventricular assist device (LVAD) implantation increased from 2009 to 2014. Data are lacking regarding trends of LVAD implantation in older adults., Objectives: To describe the trends of LVAD implantation in older adults and the clinical impact of associated procedural complications., Methods: We retrospectively analyzed the National Inpatient Sample from 2005 to 2014, calculated the percentage of older adults (>65 years of age) among those who underwent LVAD implantation, and compared their clinical characteristics. Primary outcomes were in-hospital mortality and discharge home., Results: In total, 4491 patients were included. The percentage of older adults among those receiving LVAD increased from 12.53% to 31.65% (p<0.01). Older adults were more likely to develop postoperative delirium (17.90% vs. 11.92% in younger patients; p<0.01), which portended lesser odds of discharge home., Conclusions: Delirium develops with greater incidence in older adults undergoing LVAD implantation, which decreases odds of favorable discharge disposition., Competing Interests: Declaration of Competing Interest BA, SK, SN, IAS, BK, and IDG all report receiving in-kind support from medical companies for travel and lodging, food and beverage, and education. All transactions are reported on the OpenPayments website in accordance with the Sunshine Act, and none rise to the level of a conflict of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The optimal timing for tracheostomy among patients with acute heart failure (AHF) exacerbation has been controversial, despite multiple studies assessing the utility of early tracheostomy. Our objective was to assess the trend of utilization and outcomes of early tracheostomy among patients with AHF exacerbation in the United States., Methods and Results: A retrospective cohort study using the National Inpatient Sample from 2005 to 2014 was conducted. Among those who were admitted with AHF exacerbation (n = 1,390,356), 0.26% of patients underwent tracheostomy (n = 2,571), and among them, 19.4% received early tracheostomy (n = 496). There was no significant shift in the percentage of early tracheostomy from 2008 to 2014. We used propensity score matching to compare the clinical and economic outcomes between the early tracheostomy group and late tracheostomy group. In-hospital mortality did not show any difference between the two groups (13.97% in early group vs. 18.04% in late group; p =0.163). The median total hospital cost ($53,466), total hospital length of stay (19 days), and length of stay after intubation (16 days) in the early tracheostomy group were significantly lower than in the late tracheostomy group ($73,680; 26 days; 23 days, respectively)., Conclusion: Early tracheostomy showed economic benefit with lower hospital costs and shorter length of stay, without a difference in in-hospital mortality compared to late tracheostomy., Competing Interests: Declaration of Competing Interest Dr. Lal reports employment at Optum, outside the submitted work. Other authors do not have conflict of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Myocarditis continues to present challenges in diagnosis and management. The goal of this study is to determine the occurrence and manifestations of myocarditis in a heart failure (HF) population. The analyzed patients had acute or persistent HF and were referred over a 6-year period to a quaternary HF center for advanced HF therapies including mechanical circulatory support, left ventricular assist device (LVAD) implantation, and/or heart transplantation. The histopathological diagnosis of myocarditis was made based on the presence of an inflammatory infiltrate of the myocardium, typically with associated cardiomyocyte (CMC) damage, combined as indicated with immunohistochemical and molecular biology characterization. The pathological findings were correlated with a panel of clinical parameters and clinical course of the patients. Myocarditis was identified in 36 patients, with initial diagnoses made in 10 (40%) of 25 by endomyocardial biopsy (EMB), 1 by atrial biopsy (maze procedure), 7 (2.1%) of 331 at LVAD implantation, and 18 (7.8%) of 229 in the explanted heart. There were 20 cases of lymphocytic myocarditis, 4 cases of giant cell myocarditis, 3 cases of eosinophilic myocarditis, and 9 cases of lymphohistocytic with granulomas myocarditis - cardiac sarcoidosis. EMB was performed in 25 patients and was positive in 10 (40%) of cases. Myocarditis was found in 23 explanted hearts including 18 cases de novo and 5 cases with a previously positive specimen. Of the 23 explanted hearts, 21 were nonischemic cardiomyopathy and 2 were ischemic cardiomyopathy. Our findings show that, in patients presenting to a quaternary medical center, myocarditis can be manifest as acute HF as well as a complicating factor in chronic HF., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Rescuing heterotopic heart transplantation (HHT) patients remains a challenge in the field. When a 41-year-old patient was transferred to our service, we chose a novel approach that is reported herein. The HHT had been performed over 20 years ago, and in 2016, because of complications, the patient was listed for transplant with a 1A status. For the first time, the SynCardia 50cc total artificial heart (TAH) (SynCardia Systems, LLC, Tucson, AZ) was used in an HHT patient. Investigators attained approval to use the SynCardia 50cc investigational device, as this was an emergent case with few options. The donor heart from the HHT was left in place, alongside the TAH. By leaving the donor heart from the HHT, the need for long and tedious extensive dissection around the right lung was eliminated; thereby reducing the potential risk of lung parenchymal injury, massive bleeding, and complex air leaks. The procedure was successful, and the patient underwent a successful orthotopic heart transplantation six months after being placed on TAH.

Congestive heart failure is one of the leading causes of morbidity and mortality in the United States, and left ventricular assist devices have revolutionized treatment of end-stage heart failure. Given that sleep apnea results in significant morbidity in these patients with advanced heart failure, practicing sleep physicians need to have an understanding of left ventricular assist devices. In this review, we summarize what is known about ventricular assist devices as they relate to sleep medicine., (Copyright © 2016 Elsevier Ltd. All rights reserved.)