Although Afro-Caribbean (AC) race has been associated with worse outcomes in many cardiovascular diseases, its potential association with transthyretin cardiac amyloidosis (ATTR-CA) is less understood. We aimed to assess the relationship between race and serum biomarkers, adverse cardiac remodeling, and outcomes in AC vs white ATTR-CA patients. 114 AC and 117 white patients confirmed ATTR-CA who underwent cardiac magnetic resonance (CMR) exam were identified. The relationship between race and the primary endpoint—defined by all-cause mortality or heart failure hospitalization—was assessed using Cox regression analysis. ATTR disease stage was significantly higher at diagnosis in AC vs white patients (p < 0.0001). Left (p = 0.001) and right ventricular ejection fractions (p = 0.0002) were lower and extracellular volume (58

Background Transthyretin amyloid cardiomyopathy (ATTR-CM) is a common cause of heart failure caused by deposition of transthyretin fibrils in the myocardium. ATTR-CM remains underrecognized and underdiagnosed, especially in African American (AA) populations. As a result, patients often present at an advanced stage, and little is known about racial differences in presentation or outcomes. Accordingly, we aimed to compare serum biomarkers, adverse remodeling, and survival between AA and Caucasian patients. Methods Using the SCMR registry, we retrospectively identified patients with ATTR-CM who underwent cardiac magnetic resonance (CMR) at three academic centers on 1.5T scanners using conventional imaging techniques. Clinical and CMR covariates were compared between AA and Caucasian patients using t-test, chi-squared, or Wilcoxon Rank test as appropriate. Significant relationships were controlled for mutant vs wild genotype using mutltivariable analysis. The relationship between race and survival was assessed using Cox proportional hazards. Results The analysis involved 126 patients, including 82 AA and 44 Caucasians. Significant racial differences in ATTR genotype with a higher prevalence of pathogenic gene mutation in AA (64.6% vs 31.8%).were observed with 64.6% mutant type in African Americans and 68.2% wild type in White or Asian patients. AA had a higher prevalence of hypertension, while coronary artery disease was more prevalent in caucasians. Notably, AA had significantly higher levels of BNP (459 vs 262, p=0.02) and NT-proBNP (5183 vs 2093, p=0.02) (Table 1). Regarding CMR data, African Americans had lower left (LVEF, 41.4± 13.6% vs 48.2±10.8%, p=0.005) and right ventricular ejection fraction (RVEF, 39.1±12.8% vs 45.9±11.9%, p=0.004) compared to Caucasians. After controlling for the ATTR genotype, the relationship between race and both LVEF (p=0.006) and RVEF (p=0.01) remained statistically significant. Despite these differences, there was no significant difference in mortality between the two racial groups (African American: 36 deaths (52.9%) vs White: 16 deaths (43.2%); HR 0.80 for Caucasians, 95% CI 0.45-1.45, p = 0.47). Conclusion AA with ATTR-CM present with more advanced heart failure as demonstrated by higher levels of BNP, NT-proBNP, and lower biventricular EF even after controlling for ATTR genotype. However, race was not associated with worse survival in this small multicenter study.

Introduction: Assessment of invasive hemodynamics is a critical aspect of heart failure (HF) management influencing treatment decisions. However, standard metrics including intracardiac filling pressures and cardiac output do not consistently predict clinical outcomes. The myocardial performance score (MPS) is a novel hemodynamic parameter that combines myocardial power and efficiency into a single variable. We aimed to evaluate the prognostic significance of MPS and assess whether it can improve risk stratification compared to traditional measures. Methods: All patients who underwent isolated right heart catheterization for chronic, or acute on chronic HF between 2013-2019 at our institution were retrospectively analyzed. MPS is calculated as [aortic pulsatility index (API) x cardiac power output (CPO)]/2. The primary outcome was a composite endpoint of death or need for left ventricular assist device or heart transplant over a two-year period. MPS thresholds of 0.5 and 1.0 were selected from prior analyses showing declining efficiency less than 0.5 in addition to balanced power and efficiency greater than 1.0. Kaplan-Meier curves were calculated with statistical significance determined by log-rank tests. Results: A total of 709 patients (60±14 years; 54% male) were included, of which 102 (14%) had an MPS<0.5, 169 (24%) had an MPS between 0.5-1.0, and 438 (62%) had an MPS≥1.0. Of the 607 patients with an MPS≥0.5, 379 (62%) demonstrated freedom from the composite endpoint compared to 37 (36%) patients with an MPS<0.5 (p<0.0001). An intermediate MPS (0.5≤MPS<1.0) conveyed significantly greater freedom compared to patients with a low MPS<0.5 (57% vs 36%; p<0.001), yet lower freedom compared to those with a high MPS≥1.0 (57% vs. 66%, p<0.05). An MPS<0.5 demonstrated superior risk stratification with an odds ratio for the composite endpoint at two years of 3.1 compared to 1.8 for pulmonary capillary wedge pressure>15 mmHg and cardiac index<2.0 L/min/m 2 estimated by Fick equation or thermodilution (Figure). Conclusions: MPS is a novel, advanced hemodynamic measurement that outperforms current invasive hemodynamic parameters in accurately predicting long-term clinical outcomes in all patients with heart failure.

Hypertrophic cardiomyopathy is the most common inherited cardiomyopathy, with a prevalence of 1:200 to 1:500. Cardiac amyloidosis, another cardiomyopathy caused by myocardial deposition of abnormally folded TTR protein, can be acquired or hereditary. The presence of pathogenic TTR gene variants in patients with phenotypic HCM is an underrecognized and clinically important entity.

Introduction Low aortic pulsatility index (API) is significantly associated with advanced heart failure therapies or death at 30 days in a cardiogenic shock population. Low cardiac power output (CPO) was found to be the strongest independent predictor of in-hospital mortality in patients with acute myocardial infarction and cardiogenic shock. Hypothesis We hypothesized that hemodynamic assessment of dynamic left ventricular coupling with API and myocardial reserve with CPO after milrinone drug study would assist with risk stratification of patients who have a low API at baseline. Methods We retrospectively analyzed patients with decompensated heart failure or cardiogenic shock undergoing right heart catheterization with milrinone drug study (milrinone bolus of 5 mcg/kg/min over 10 min) at our institution. API was calculated as (SBP-DBP)/PCWP and CPO was calculated as (MAP*CO)/451. Both hemodynamic variables were measured pre- and post-milrinone drug study for risk stratification. Optimal cut points with ROC curves were used for Kaplan-Meier analysis of the composite endpoint of survival at one year, free from LVAD or heart transplant. Results 224 patients underwent right heart catheterization with milrinone drug study. 117 patients (52%) had a baseline API < 1.45 and 107 patients (48%) had a baseline API ≥ 1.45 (static assessment) on initial hemodynamics. Kaplan-Meier analysis demonstrated 53% freedom from the composite endpoint at one year in patients with baseline API ≥ 1.45 compared to 32% in patients with baseline API < 1.45 (p < 0.001). Of the decompensated patients without coupling (baseline API < 1.45), patients that were able to demonstrate left ventricular recoupling after dynamic assessment with milrinone drug study (post-milrinone API > 2.2) had a lower likelihood of the composite endpoint than those that did not demonstrate recoupling (post-milrinone API ≤ 2.2); Kaplan Meier curve 55% vs. 73%, respectively (p=0.046). Similarly, patients with adequate myocardial reserve (post-milrinone CPO ≥ 0.77) had a lower likelihood of the composite endpoint than those with inadequate myocardial reserve (post-milrinone CPO < 0.77); Kaplan Meier curve 64% vs. 78%, respectively (p=0.039). Conclusions Hemodynamic assessment of dynamic left ventricular coupling with API and myocardial reserve with CPO improves risk stratification compared to static baseline measurements and predicts outcomes of LVAD, heart transplant, or death at one year in patients with decompensated heart failure and cardiogenic shock.

Aims:Pulmonary artery catheter haemodynamics are associated with improved survival in cardiogenic shock (CS). We investigated the utility of aortic pulsatility index (API) and cardiac power output (CPO) as surrogates for left ventricular (LV) coupling and myocardial reserve, respectively, in patients with CS undergoing dynamic assessment after a milrinone bolus. Methods and results:Patients with SCAI Stage C CS underwent a milrinone drug study (50 mcg/kg bolus infused over 10 min) to assess inotropic response. Haemodynamic measurements were obtained at baseline and following the bolus. Aortic pulsatility index and CPO were used to risk-stratify patients with the incidence of LV assist device (LVAD), orthotopic heart transplantation (OHT), or death at 1 year as the primary composite endpoint. Two hundred and twenty-four patients in SCAI Stage C CS underwent haemodynamics prior to milrinone bolus, and 117 patients had low baseline API < 1.45. Of the 117 patients, 88 had a final API < 2.2 after milrinone load, consistent with LV decoupling, in which 73% met the composite endpoint. The remaining 29 patients had a final API ≥ 2.2 consistent with LV recoupling, and only 55% met the composite endpoint (P = 0.046). Of the 117 patients, 40 patients had low myocardial reserve (final CPO < 0.77 W), in which 78% met the composite endpoint. Of the 77 patients who demonstrated myocardial reserve (final CPO ≥ 0.77 W), only 64% met the composite endpoint (P = 0.039). Conclusion:The use of API and CPO in a dynamic assessment after provocative testing led to improved risk stratification in patients with SCAI Stage C CS for clinical outcomes including LVAD, OHT, or death at 1 year.

Beginning in 2005, the United States heart allocation system grouped high-urgency transplant candidates into a single status. This 3-tier system led to overcrowding in the highest-urgency status category, including prolonged waiting times and concerns about inequities in allocation. 1 Chouairi FC Fuery M Clark KA Mullan CW Stewart J Caraballo C et al. Evaluation of racial and ethnic disparities in cardiac transplantation. J Am Heart Assoc. 2021; 10e021067 Crossref Scopus (18) Google Scholar The revised 7-tiered U.S. heart-allocation policy implemented in October 2018 aimed to improve risk stratification to better facilitate geographic sharing of organs and improve patients’ outcomes. 2 Davies RR Farr M Silvestry S Callahan LR Edwards L Meyer DM et al. The new United States heart allocation policy: progress through collaborative revision. J Heart Lung Transplant. 2017; 36: 595-596 Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar An expected byproduct of improved differentiation among the urgencies of various transplant candidates is that fewer exception requests would be necessary secondary to the increased categorical nature built into the new hierarchical system. However, early reports of the new system demonstrate that, contrary to intention, status exceptions have since increased from 57 (3.5%) candidates in the 10-month prepolicy cohort to 241 (15%) candidates in the 10-month postpolicy cohort 3 Parker WF Chung K Anderson AS Siegler M Huang ES Churpek MM. Practice changes at U.S. transplant centers after the new adult heart allocation policy. J Am Coll Cardiol. 2020; 75: 2906-2916 Crossref PubMed Scopus (63) Google Scholar ; overall, 30% of patients in the new allocation system were listed with exceptions. 4 Topkara VK Clerkin KJ Fried JA Griffin J Raikhelkar J Hi Lee S et al. Exception status listing in the new adult heart allocation system: a new solution to an old problem?. Circulation: Heart Fail. 2021; 14e007916 Crossref PubMed Scopus (9) Google Scholar The general characteristics of all heart transplant patients listed as exceptions have been investigated, but the analyses of these patients have not been stratified by status. 4 Topkara VK Clerkin KJ Fried JA Griffin J Raikhelkar J Hi Lee S et al. Exception status listing in the new adult heart allocation system: a new solution to an old problem?. Circulation: Heart Fail. 2021; 14e007916 Crossref PubMed Scopus (9) Google Scholar We aimed to report the characteristics of patients listed for heart transplant as Status One or Two, by exception, in the new allocation system.

The accurate assessment of hemodynamics is paramount to providing timely and efficacious care for patients presenting in cardiogenic shock. Recently, the regular use of the pulmonary artery catheter in cardiogenic shock has had a resurgence with emerging data indicating improved survival in the modern era. Optimal multidisciplinary management of advanced heart failure and cardiogenic shock relies on our ability to effectively communicate and understand the complete hemodynamic assessment. Standardization of data acquisition and a renewed focus on the physiological processes, and thresholds driving disease progression, including the coupling ratio and myocardial reserve, are needed to fully understand and interpret the hemodynamic assessment. This State-of-the-Art review discusses best practices in the cardiac catheterization laboratory as well as emerging data on the prognostic role of emerging advanced hemodynamic parameters. (J Cardiac Fail 2023;29:1543-1555)

PURPOSE Tolvaptan, a selective vasopressin type-2 antagonist, has been shown to increase serum sodium (Na) and urine output in hyponatremic left ventricular assist device (LVAD) patients in retrospective studies. In this prospective randomized pilot study, we aimed to assess the efficacy of tolvaptan in this population. METHODS We conducted a prospective, randomized, non-blinded pilot study of LVAD recipients with post-operative hyponatremia (Na < 135 mEq/L) (NCT05408104). Eligible participants were randomized to receive tolvaptan 15 mg daily in addition to usual care versus usual care alone. The primary outcome was a change in Na level and estimated glomerular filtration rate (eGFR), from the first post-operative day of hyponatremia (the day of randomization) to discharge. RESULTS A total of 33 participants were enrolled, and 28 underwent randomization (median age 55 [IQR 50-62]), 21% women, 54% Black, 32% ischemic cardiomyopathy, median baseline Na 135 (IQR 134-138). Fifteen participants were randomized to tolvaptan (TLV) and 13 were randomized to usual care alone (No-TLV). Mean change in Na from randomization to discharge in the TLV group was 2.7 mEq/L (95%CI 0.7-4.7, p = 0.013) and 1.8 (95%CI 0.5-4.0, p = 0.11) in the No-TLV group, though baseline and final Na levels were similar between groups. The mean change in eGFR was 2.6 ml/min/1.73 m2 (95%CI 10.1-15.3, p = 0.59) in TLV versus 7.5 ml/min/1.73 m2 (95%CI 5.2-20.2, p = 0.15) in No-TLV. TLV participants had significantly more urine output than No-TLV patients during their first 24 h after randomization (3294 vs 2155 ml, p = 0.043). CONCLUSION TLV significantly increases urine output, with nominal improvement in Na level, in hyponatremic post-operative LVAD patients without adversely impacting renal function.

Objective: Axillary Intra-aortic balloon pump (IABP) has been increasingly utilized for hemodynamic support in heart failure patients. Vascular complications associated with axillary IABP such as dissection or rupture are relatively rare but not negligible that could negatively affect clinical outcomes. We summarized our experiences. Methods: This is a retrospective study reviewing of all patients receiving an axillary IABP between June 2016 and November 2020. A total of 199 patients underwent percutaneous axillary IABP placement. 6 patients (6/199, 3.0%) were complicated with arterial/aor tic dissection or rupture during the procedures or the course of treatment. We described their clinical presentations and outcomes. Results: Vascular complications included acute type A aortic dissection in 2 patients, descending aortic rupture in 1 patient, abdominal aortic rupture along with type B aortic dissection in 1 patient, and the localized left subclavian artery dissection in 2 patient. 2 type A aortic dissection cases were surgically treated: 1 with emergent left ventricle assist device and ascending aorta replacement, the other with emergent left ventricle assist device. Emergent endovascular treatment was successfully performed in 2 aortic rupture cases. The left subclavian artery dissection cases were managed medically. The postoperative/treatment course was uneventful in all patients. Conclusion: Percutaneous axillary IABP therapy can cause significant vascular complications. Early diagnosis and prompt treatment would be the key to improve the clinical outcomesv.

The purpose of this study is to investigate the early and late outcomes of axillary intra-aortic balloon pump (IABP) implantation as a bridge to heart transplantation, comparing the grafted technique with the percutaneous technique. Between July 2009 and January 2020, 163 patients underwent an axillary IABP insertion as a bridge to heart transplantation. Among them, 97 patients underwent axillary IABP implantation through a graft sutured onto the axillary artery (Group A) and 66 patients underwent percutaneously (Group B). Propensity matching identified 53 matched pairs for analysis (C-statistics 0.741). The primary outcomes of interest included IABP-related complications, success rate of a bridge to transplantation, in-hospital mortality, and late survival. In the propensity-score matched cohort, there were no significant differences in the baseline characteristics between the two groups. The operation time was significantly longer in Group A than in Group B (141.5 ± 38.3 min vs 42.7 ± 19.3 min, p < 0.01). The complication rates including stroke, re-exploration for bleeding, and aortic event were not significantly different between Group A and B. However, Group A required more transfusion and re-exploration for bleeding. The success rate of a bridge to transplantation was similar between Group A (47/53, 88.7

Purpose: Prior studies have identified public insurance as a risk factor for inferior outcomes after advanced heart failure therapies such as heart transplant due to high costs of care. Current data on the association of primary health insurance payer type with outcomes after left ventricular assist device (LVAD) implantation are limited and conflicting. Methods: 209 patients who underwent LVAD implantation at a US tertiary care medical center between January 2010 and April 2020 were retrospectively enrolled in this study. Univariate Kaplan-Meier with log-rank test was used to study overall survival as well as freedom from readmission at 1 and 3 years post LVAD implant among the three cohorts by primary insurance type (Medicaid, Medicare, or commercial). Results: Of the 209 patients, 38 (18.2%) had Medicaid, 93 (44.4%) had Medicare, and 78 (37.3%) had commercial insurance. There was no significant difference in all-cause mortality among patient cohorts by payer type at 1 year (P=0.737) or 3 years (P=0.526) following LVAD implantation. Similarly, health insurance type was not significantly associated with difference in freedom from readmission at 1 year (P=0.608) or 3 years (P=0.628). Conclusion: Insurance type has been reported to correlate with clinical outcomes following heart failure therapies due to the impact of socioeconomic factors. However, it appears that this distinction does not extend to the LVAD population in this single-center study. These unexpected findings may reflect the rigorous institutional follow-up protocols that closely monitor patient status and assess for potential device complications, which may have helped mitigate the impact of low socioeconomic status on post-LVAD outcomes.

BACKGROUND:Invasive hemodynamic variables obtained from right heart catheterization have been used for risk-stratifying patients with advanced heart failure (HF). However, there is a paucity of data on the prognostic value of invasive hemodynamic variables in patients with left ventricular assist devices (LVAD). We hypothesized that cardiac power output (CPO), cardiac power efficiency (CPE), and left ventricular stroke work index (LVSWI) can serve as prognostic markers in patients with LVADs.METHODS:Baseline hemodynamic data from patients who had LVAD ramp studies at our institution from 4/2014 to 7/2018 were prospectively collected, from which advanced hemodynamic variables (CPO, CPE, and LVSWI) were retrospectively analyzed. Univariate and multivariable analyses were performed for hemocompatibility-related adverse events (HRAE), HF admissions, and mortality.RESULTS:Ninety-one participants (age 61 ± 11 years, 34% women, 40% Black or African American, and 38% ischemic cardiomyopathy) were analyzed. Low CPE was significantly associated with mortality (HR 2.42, 95% CI 1.02-5.74, p = 0.045) in univariate analysis and Kaplan-Meier analysis (p = 0.04). Low LVSWI was significantly associated with mortality (HR 2.13, 95% CI 1.09-4.17, p = 0.03) in univariate analysis and Kaplan-Meier analysis (p = 0.02). CPO was not associated with mortality. CPO, CPE, and LVSWI were not associated with HRAE or HF admissions.CONCLUSIONS:Advanced hemodynamic variables can serve as prognostic indicators for patients with LVADs. Low CPE and LVSWI are prognostic for higher mortality, but no variables were associated with HF admissions or HRAEs.

Purpose: Socioeconomic status (SES) is hypothesized to be an important predictor of clinical outcomes following left ventricular assist device (LVAD) implantation due to high costs of care. We investigated whether median income of a patient’s residing neighborhood predicts mortality or rate of readmission in LVAD therapy. Methods: 210 patients implanted with an LVAD between January 2010 and April 2020 at a single tertiary care center in the United States were retrospectively enrolled in this study. Patients were classified into tertiles based on published neighborhood median income data and compared for survival and freedom from readmission. Results: The study cohort comprised 135 unique ZIP codes, with 34 (25.2%) above and 101 (74.8%) below the national median income level. The low, middle, and high income groups had a total survivorship of 92.8%, 95.5%, and 92.5% at 1 year and 85.5%, 89.4%, and 85.1% at 3 years, respectively. Low median income was not significantly associated with worse outcomes at 1-year (P=0.400) and 3-years (P=0.689) following LVAD implantation. There was similarly no significant difference in freedom from readmissions at 3 years. Conclusion: LVAD recipients with a lower geographic median income were not more likely to experience worse outcomes after LVAD implantation. These findings were contrary to prior published reports showing worse clinical outcomes in heart transplant patients with lower SES patients. Factors such as institution-specific and system-wide patient assistance programs and risk factor modification measures may have mitigated the impact of reduced SES on patient care and helped eliminate the effect of income disparity on long-term clinical outcome post LVAD implantation. Further research to study such potential association is warranted.

Background The initial derivation of cardiac power output (CPO) included the difference between mean arterial pressure (MAP) and right atrial pressure (RAP) in the numerator, before multiplying by cardiac output (CO). In common use, CPO is calculated without RAP. Whereas the omission of RAP from the CPO calculation may be inconsequential for those with normal right-sided pressures, we hypothesized that the inclusion of RAP will enhance the prognostic performance of this parameter in those with elevated RAP. Methods We retrospectively analyzed consecutive patients undergoing right heart catheterization with milrinone drug study at our institution (2/2013-11/2019). CPO was calculated as [(MAP-RAP)xCO)]/451 Watts (W), and was then analyzed with RAP above or below the median. Univariable analysis was done for the primary outcome of freedom from advanced therapies, defined as need for inotropes, temporary mechanical circulatory support, left ventricular assist device, orthotopic heart transplant, or death at 30 days. Receiver operator characteristic analyses were completed to determine the optimal cutpoints, and Kaplan-Meier (KM) analyses were implemented. Results The cohort included 224 patients, median age 57 (IQR 48-66) years, 34% women, and 31% ischemic cardiomyopathy. Median RAP was 13 mmHg. CPO with RAP < 13 were older (61 vs 56 years-old, p=0.001) and had a lower ejection fraction (19% vs 23%, p=0.02) than CPO with RAP ≥ 13. Median CPO with RAP ≤ 13 (n=120) was 0.60 W (IQR 0.49-0.73) and CPO with RAP > 13 (n=104) was 0.52 W (IQR 0.40-0.65). In univariable analysis CPO with RAP ≤ 13 (OR 0.003, 95%CI 0.00-0.05, p<0.001) and CPO with RAP > 13 (OR 0.004, 95%CI 0.00-0.08, p<0.001) were both significantly associated with the primary outcome. In KM analysis, CPO with RAP ≤ 13 had no significant difference in the primary outcome (54% CPO < 0.67 W vs 73% CPO ≥ 0.67 W, p=0.10), while CPO with RAP > 13 had a significant difference in the primary outcome (55% CPO < 0.67 W vs 87% CPO ≥ 0.67 W, p=0.01). Conclusion In the setting of elevated, compared to normal, RAP, there is a significant difference in 30-day clinical outcomes when assessing heart failure patients using the original CPO calculation. The initial derivation of cardiac power output (CPO) included the difference between mean arterial pressure (MAP) and right atrial pressure (RAP) in the numerator, before multiplying by cardiac output (CO). In common use, CPO is calculated without RAP. Whereas the omission of RAP from the CPO calculation may be inconsequential for those with normal right-sided pressures, we hypothesized that the inclusion of RAP will enhance the prognostic performance of this parameter in those with elevated RAP. We retrospectively analyzed consecutive patients undergoing right heart catheterization with milrinone drug study at our institution (2/2013-11/2019). CPO was calculated as [(MAP-RAP)xCO)]/451 Watts (W), and was then analyzed with RAP above or below the median. Univariable analysis was done for the primary outcome of freedom from advanced therapies, defined as need for inotropes, temporary mechanical circulatory support, left ventricular assist device, orthotopic heart transplant, or death at 30 days. Receiver operator characteristic analyses were completed to determine the optimal cutpoints, and Kaplan-Meier (KM) analyses were implemented. The cohort included 224 patients, median age 57 (IQR 48-66) years, 34% women, and 31% ischemic cardiomyopathy. Median RAP was 13 mmHg. CPO with RAP < 13 were older (61 vs 56 years-old, p=0.001) and had a lower ejection fraction (19% vs 23%, p=0.02) than CPO with RAP ≥ 13. Median CPO with RAP ≤ 13 (n=120) was 0.60 W (IQR 0.49-0.73) and CPO with RAP > 13 (n=104) was 0.52 W (IQR 0.40-0.65). In univariable analysis CPO with RAP ≤ 13 (OR 0.003, 95%CI 0.00-0.05, p<0.001) and CPO with RAP > 13 (OR 0.004, 95%CI 0.00-0.08, p<0.001) were both significantly associated with the primary outcome. In KM analysis, CPO with RAP ≤ 13 had no significant difference in the primary outcome (54% CPO < 0.67 W vs 73% CPO ≥ 0.67 W, p=0.10), while CPO with RAP > 13 had a significant difference in the primary outcome (55% CPO < 0.67 W vs 87% CPO ≥ 0.67 W, p=0.01). In the setting of elevated, compared to normal, RAP, there is a significant difference in 30-day clinical outcomes when assessing heart failure patients using the original CPO calculation.

We sought to assess the impact of the aortic root geometry on developing de novo aortic insufficiency (AI) in patients undergoing left ventricular assist device (LVAD). In total, 114 patients underwent LVAD implantation between February 2016 and January 2020 were included in this study (HeartMate3 N = 68, HeartWare N = 46). Significant aortic insufficiency was defined as mild-to-moderate or greater in echocardiography. The cohort was divided into two groups; those who developed significant AI (Group AI: n = 13) and did not (Group non-AI: n = 101). The primary outcomes of interest included late survival and predictors for significant AI. The patients in Group AI were older than Group non-AI (62.6 ± 11.9 vs 51.3 ± 14.0 years, p < 0.01). The diameter of proximal ascending aorta in Group AI was larger than Group non-AI (31.0 ± 5.0 vs 27.4 ± 4.3 mm, p < 0.01). Aortic valve remained closed in 53.8% in Group AI and 36.6% in Group non-AI (p = 0.24). The late survival was not significantly different between the groups (67.1% vs 76.0% at 3 years, log rank = 0.97). The Cox hazard model showed that larger proximal ascending aortic diameter/BSA (HR 1.55, CI 1.19–2.04, p < 0.01) and not-opening aortic valve (HR 4.73, CI 1.43–16.9, p = 0.01) were independent risk factors for significant AI. The cutoff value of proximal ascending aortic diameter/BSA was 15.5 (area under curve: 0.770, sensitivity: 0.69, specificity: 0.79). Dilated proximal ascending aorta at the time of LVAD surgery and not-opening aortic valve during follow-up were associated with the incidence of de novo significant AI.

Purpose of review The aim of this review is to discuss racial and sex disparities in the management and outcomes of patients with acute decompensated heart failure (ADHF). Recent findings Race and sex have a significant impact on in-hospital admissions and overall outcomes in patients with decompensated heart failure and cardiogenic shock. Black patients not only have a higher incidence of heart failure than other racial groups, but also higher admissions for ADHF and worse overall survival, while women receive less interventions for cardiogenic shock complicating acute myocardial infarction. Moreover, White patients are more likely than Black patients to be cared for by a cardiologist than a noncardiologist in the ICU, which has been linked to overall improved survival. In addition, recent data outline inherent racial and sex bias in the evaluation process for advanced heart failure therapies indicating that Black race negatively impacts referral for transplant, women are judged more harshly on their appearance, and that Black women are perceived to have less social support than others. This implicit bias in the evaluation process may impact appropriate timing of referral for advanced heart failure therapies. Summary Though significant racial and sex disparities exist in the management and treatment of patients with decompensated heart failure, these disparities are minimized when therapies are properly utilized and patients are treated according to guidelines.