Background: Our current understanding of right heart failure (RHF) post-left ventricular assist device (LVAD) is lacking. Recently, a new Interagency Registry for Mechanically Assisted Circulatory Support definition of RHF was introduced. Based on this definition, we investigated natural history, risk factors, and outcomes of post-LVAD RHF. Methods: Patients implanted with continuous flow LVAD between June 2, 2014, and June 30, 2016 and registered in the Interagency Registry for Mechanically Assisted Circulatory Support/Society of Thoracic Surgeons Database were included. RHF incidence and predictors, and survival after RHF were assessed. The manifestations of RHF which were separately analyzed were elevated central venous pressure, peripheral edema, ascites, and use of inotropes. Results: Among 5537 LVAD recipients (mean 57±13 years, 49% destination therapy, support 18.9 months) prevalence of 1-month RHF was 24%. Of these, RHF persisted at 12 months in 5.3%. In contrast, de novo RHF, first identified at 3 months, occurred in 5.1% and persisted at 12 months in 17% of these, and at 6 months occurred in 4.8% and persisted at 12 months in 25%. Higher preimplant blood urea nitrogen (ORs,1.03–1.09 per 5 mg/dL increase; P<0.0001), previous tricuspid valve repair/replacement (ORs, 2.01–10.09; P<0.001), severely depressed right ventricular systolic function (ORs,1.17–2.20; P=0.004); and centrifugal versus axial LVAD (ORs,1.15–1.78; P=0.001) represented risk factors for RHC incidence at 3 months. Patients with persistent RHF at 3 months had the lowest 2-year survival (57%) while patients with de novo RHF or RHF which resolved by 3 months had more favorable survival outcomes (75% and 78% at 2 years, respectively; P<0.001). Conclusions: RHF at 1 or 3 months post-LVAD was a common and frequently transient condition, which, if resolved, was associated with relatively favorable prognosis. Conversely, de novo, late RHF post-LVAD (>6 months) was more frequently a persistent disorder and associated with increased mortality. The 1-, 3-, and 6-month time points may be used for RHF assessment and risk stratification in LVAD recipients.

Checkpoint inhibitors decrease the progression of many cancers. However, the experience in immunosuppressed patients is limited, with reports of possible serious adverse events. We present a heart transplant recipient treated with pembrolizumab for metastatic melanoma who developed fatal rejection. The patient was a 29 year-old man who underwent heart transplantation at the age of 10 years for congenital heart disease. Seventeen years after transplant, he was diagnosed with scalp melanoma pT3a, N2a, M0, Stage IIIA, positive for BRAF V600E mutation treated with excision, which metastasized to his lungs and brain a year later. Dabrafenib and trametinib were started with transient response. Additional options and their risks were discussed, and pembrolizumab was started 4 months later due to the incomplete response to previous therapy. Five days after initiation the patient presented with moderate cellular rejection and possible antibody mediated rejection (ISHLT Grade 2R, pAMR 1H). Pembrolizumab was discontinued, and he was treated with steroids. Seven months later he presented in cardiogenic shock and severe coronary allograft vasculopathy. Biopsy was negative for cellular rejection, but suspicious for antibody mediated rejection (ISHLT Grade 0R, pAMR 1H), and he had a new serum alloantibody. Despite steroids and plasmapheresis he remained in refractory cardiogenic shock and died of cardiac arrest.

Background In the CardioMEMS Post Approval Study (PAS), pulmonary artery (PA) pressure monitoring in patients with NYHA Class III heart failure (HF) reduced HF hospitalizations (HFH) by 57%. Older patients with HF have both higher risks of HFH and the competing risk of all-cause hospitalization (ACH) compared to a younger cohort. We hypothesized that older patients have a decreased benefit from a CardioMEMS device due to the greater prevalence of non-cardiovascular comorbidities and death. Methods The PAS compared the rate of HF hospitalization in the 1 year prior to CardioMEMS implant to the rate in 1 year after implant with an overall 57% reduction in the rate of HFH. Patients were placed in three age categories: <70, 70-80 and >80 years. Baseline characteristics and PA pressures were compared at baseline and the paired change in pressures over 1 year. Hospitalization rates before and after implant were compared using the Andersen-Gill model. Results Older patients were more likely to have EF >40%, ischemic etiology, hypertension and CKD, but diabetes mellitus was less prevalent. The baseline PA diastolic (PAD) pressures were slightly lower in the older group. At 12 months, PA systolic and PAD was lower in all age groups (Table). All age groups had significant reductions in both HFH and all-cause hospitalizations (ACH) at 1 year (p<0.0001 for HFH and ACH, all age groups). Comparison across age groups demonstrated no significant difference in the reduction of HFH, ACH, or in time to first HFH. Conclusions Although older patients with HF have a higher mortality and more comorbidities, the benefit of CardioMEMS in reducing HFH and all-cause hospitalizations was similar across the age categories. The proportion of HFH was decreased after CardioMEMS in all age categories due to a reduction in HFH. In the CardioMEMS Post Approval Study (PAS), pulmonary artery (PA) pressure monitoring in patients with NYHA Class III heart failure (HF) reduced HF hospitalizations (HFH) by 57%. Older patients with HF have both higher risks of HFH and the competing risk of all-cause hospitalization (ACH) compared to a younger cohort. We hypothesized that older patients have a decreased benefit from a CardioMEMS device due to the greater prevalence of non-cardiovascular comorbidities and death. The PAS compared the rate of HF hospitalization in the 1 year prior to CardioMEMS implant to the rate in 1 year after implant with an overall 57% reduction in the rate of HFH. Patients were placed in three age categories: <70, 70-80 and >80 years. Baseline characteristics and PA pressures were compared at baseline and the paired change in pressures over 1 year. Hospitalization rates before and after implant were compared using the Andersen-Gill model. Older patients were more likely to have EF >40%, ischemic etiology, hypertension and CKD, but diabetes mellitus was less prevalent. The baseline PA diastolic (PAD) pressures were slightly lower in the older group. At 12 months, PA systolic and PAD was lower in all age groups (Table). All age groups had significant reductions in both HFH and all-cause hospitalizations (ACH) at 1 year (p<0.0001 for HFH and ACH, all age groups). Comparison across age groups demonstrated no significant difference in the reduction of HFH, ACH, or in time to first HFH. Although older patients with HF have a higher mortality and more comorbidities, the benefit of CardioMEMS in reducing HFH and all-cause hospitalizations was similar across the age categories. The proportion of HFH was decreased after CardioMEMS in all age categories due to a reduction in HFH.

IMPORTANCE Heart failure with recovered ejection fraction (HFrecEF) is a recently recognized phenotype of patients with a history of reduced left ventricular ejection fraction (LVEF) that has subsequently normalized. It is unknown whether such LVEF improvement is associated with improvements in health status. OBJECTIVE To examine changes in health-related quality of life in patients with heart failure with reduced ejection fraction (HFrEF) whose LVEF normalized, compared with those whose LVEF remains reduced and those with HF with preserved EF (HFpEF). DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study was conducted at a tertiary care hospital from November 2016 to December 2018. Consecutive patients seen in a heart failure clinic who completed patient-reported outcome assessments were included. Clinical data were abstracted from the electronic health record. Data analysis was completed from February to December 2020. MAIN OUTCOMES AND MEASURES Changes in Kansas City Cardiomyopathy Questionnaire overall summary score, Visual Analog Scale score, and Patient-Reported Outcomes Measurement Information System domain scores on physical function, fatigue, depression, and satisfaction with social roles over 1-year follow-up. RESULTS The study group included 319 patients (mean [SD] age, 60.4 [15.5] years; 120 women [37.6%]). At baseline, 212 patients (66.5%) had HFrEF and 107 (33.5%) had HFpEF. At a median follow-up of 366 (interquartile range, 310-421) days, LVEF had increased to 50% or more in 35 patients with HFrEF (16.5%). Recovery of systolic function was associated with heart failure-associated quality-of-life improvement, such that for each 10% increase in LVEF, the Kansas City Cardiomyopathy Questionnaire score improved by an mean (SD) of 4.8 (1.6) points (P = .003). Recovery of LVEF was also associated with improvement of physical function, satisfaction with social roles, and a reduction in fatigue. CONCLUSIONS AND RELEVANCE Among patients with HFrEF in this study, normalization of left ventricular systolic function was associated with a significant improvement in health-related quality of life.

Purpose The complex anatomy and different contraction patterns of the different right ventricular (RV) wall segments has made it challenging to predict acute RV failure (ARVF) in patients receiving a left ventricular assist device (LVAD). We sought to improve the prediction of ARVF after LVAD by performing a comprehensive 18-segment strain (ε) analysis of the RV. Methods Prospectively enrolled LVAD recipients had a right heart catheterization and echocardiogram prior to implant. From RV-focused views (Figure 1A), 18-segment ε was performed and indexed to pulmonary arterial elastance (Ea [PV]). ARVF was defined as need for RVAD, inotropes for >14 days or pulmonary vasodilator for >48 hours post-LVAD. Logistic regression was used to identify associations between specific parameters and ARVF. Results ARVF occurred in 15 of 30 patients enrolled. Lower pulmonary artery pulsatility index (PAPi), TAPSE and basal free wall (FW) (basal anterior, lateral and posterior FW) segmental ε/Ea (PV) were significantly associated with ARVF. Indexed basal FW segmental strain provided incremental predictive value over PAPi and TAPSE (Figure 1B). Conclusion Prediction of ARVF in LVAD candidates can be improved by adding comprehensive RV segmental strain analysis to traditional echocardiographic and hemodynamics parameters.

"Cold and dry" patients with advanced heart failure may not derive equal benefit from LVAD therapy as those who are "cold and wet". This observation warrants further investigation.

OBJECTIVES:The aim of this study was to evaluate the impact of a shared-care model on outcomes in patients with left ventricular assist devices (LVADs) living in remote locations. BACKGROUND:Health care delivery through shared-care models has been shown to improve outcomes in patients with chronic diseases. However, the impact of shared-care models on outcomes in patients with LVAD is unknown. METHODS:LVAD recipients in the authors' program (2007 to 2018) were classified based on the levels of care provided and training and resources used: level 1, was defined as outpatient primary care without LVAD-specific care; level 2 was level 1 services and outpatient LVAD-specific care; level 3 was level 2 services and inpatient LVAD-specific care and implantation center (IC). The Kaplan-Meier method was used to compare rates of survival, bleeding, pump thrombosis, infection, neurologic events, and readmissions among levels of care. RESULTS:A total of 336 patients were included, with 255 patients (75.9%) cared for in shared-care facilities. Median follow-up was 810 (interquartile range: 321 to 1,096) days. In comparison to patients cared for by IC, patients at levels 2 and 3 shared-care centers had similar rates of death, bleeding, neurologic events, pump thromboses, and infections. However, the rates of death, pump thromboses, and infections were higher for level 1 patients than in IC patients. CONCLUSIONS:Shared health care is an effective strategy to deliver care to patients with LVAD living in remote locations. However, patients in shared-care facilities unable to provide LVAD-specific care are at higher risk of unfavorable outcomes. Availability of LVAD-specific care should be strongly considered during patient selection and every effort made to ensure LVAD-specific training and resources are available at shared-care facilities.

Background Outcomes of patients with advanced heart failure (HF) due to restrictive cardiomyopathy (RCM) remain unfavorable in spite of advances in HF therapies. Left ventricular assist devices (LVADs) are a standard therapeutic option for patients with advanced HF, however there is limited data to support LVAD implantation in these patients. The purpose of this study was to examine outcomes in patients with end-stage RCM following LVAD implantation when compared with those with dilated cardiomyopathies (DCM). Methods The International Registry for Mechanically Assisted Circulatory Support (IMACS) registry was queried for all patients with RCM (n = 179) and DCM (n = 15,335) who underwent durable LVAD implantation between January 2013 and September 2017. Patients with RCM were grouped into amyloidosis, sarcoidosis, radiotherapy, idiopathic and other forms of RCM. Baseline patient characteristics, survival, and adverse events were compared among the groups. Results Patients with RCM had a mean age of 56 years and were predominately male (78.9%). Echocardiograms of patients with RCM had significantly smaller left ventricular end-diastolic diameter (LVEDD) compared to DCM (6.3 cm vs 6.8 cm p <0.001) and similar distribution in ejection fraction (50.9% with EF < 20% vs 57.4% p = 0.76, respectively). There was no significant difference in mortality (25.1% vs 21.5%, p = 0.234) or time to death (9.3 ± 11.9 months vs 10.2 ± 11.2 months, p = 0.567) between the groups. There were also similar rates of stroke (15.6% vs 16.2%, p = 0.829), bleeding (37.4% vs 35.9%, p = 0.678), driveline infection (12.3% vs 15.2%, p 0.282), and pump thrombosis (0 % vs 0.8%). When comparing subgroups of RCM, patients with amyloid cardiomyopathy were significantly older with a mean age of 62 (55-71) and had smaller LVEDD 4.7 cm (3.9-5.3) but there were no statistically significant differences in mortality or adverse events between the RCM subgroups Conclusions In this analysis of an international registry, we demonstrated that patients with RCM have similar outcomes compared with patients with DCM following LVAD implantation. This observation invites future prospective investigations on validating our findings and on identifying challenges in regards to LVAD implantation in patients with advanced HF due to RCM. Outcomes of patients with advanced heart failure (HF) due to restrictive cardiomyopathy (RCM) remain unfavorable in spite of advances in HF therapies. Left ventricular assist devices (LVADs) are a standard therapeutic option for patients with advanced HF, however there is limited data to support LVAD implantation in these patients. The purpose of this study was to examine outcomes in patients with end-stage RCM following LVAD implantation when compared with those with dilated cardiomyopathies (DCM). The International Registry for Mechanically Assisted Circulatory Support (IMACS) registry was queried for all patients with RCM (n = 179) and DCM (n = 15,335) who underwent durable LVAD implantation between January 2013 and September 2017. Patients with RCM were grouped into amyloidosis, sarcoidosis, radiotherapy, idiopathic and other forms of RCM. Baseline patient characteristics, survival, and adverse events were compared among the groups. Patients with RCM had a mean age of 56 years and were predominately male (78.9%). Echocardiograms of patients with RCM had significantly smaller left ventricular end-diastolic diameter (LVEDD) compared to DCM (6.3 cm vs 6.8 cm p <0.001) and similar distribution in ejection fraction (50.9% with EF < 20% vs 57.4% p = 0.76, respectively). There was no significant difference in mortality (25.1% vs 21.5%, p = 0.234) or time to death (9.3 ± 11.9 months vs 10.2 ± 11.2 months, p = 0.567) between the groups. There were also similar rates of stroke (15.6% vs 16.2%, p = 0.829), bleeding (37.4% vs 35.9%, p = 0.678), driveline infection (12.3% vs 15.2%, p 0.282), and pump thrombosis (0 % vs 0.8%). When comparing subgroups of RCM, patients with amyloid cardiomyopathy were significantly older with a mean age of 62 (55-71) and had smaller LVEDD 4.7 cm (3.9-5.3) but there were no statistically significant differences in mortality or adverse events between the RCM subgroups In this analysis of an international registry, we demonstrated that patients with RCM have similar outcomes compared with patients with DCM following LVAD implantation. This observation invites future prospective investigations on validating our findings and on identifying challenges in regards to LVAD implantation in patients with advanced HF due to RCM.

Using serial analysis of myocardial gene expression employing endomyocardial biopsy starting material in a dilated cardiomyopathy cohort, we show that mRNA expression of the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) cardiac myocyte receptor ACE2 is up-regulated with remodeling and with reverse remodeling down-regulates into the normal range. The proteases responsible for virus-cell membrane fusion were expressed but not regulated with remodeling. In addition, a new candidate for SARS-CoV-2 cell binding and entry was identified, the integrin encoded by ITGA5. Up-regulation in ACE2 in remodeled left ventricles may explain worse outcomes in patients with coronavirus disease 2019 who have underlying myocardial disorders, and counteracting ACE2 up-regulation is a possible therapeutic approach to minimizing cardiac damage.

BackgroundThe COVID-19 pandemic disrupted the way care is delivered to patients with chronic conditions such as heart failure (HF). Many outpatient encounters are now conducted virtually via telehealth. Whether virtual visit for HF results in similar type of interventions as when the patient is seen in person is not known.MethodsStarting on March 15, 2020, all non-time sensitive outpatient in-person appointments at our institution were cancelled and transitioned to virtual appointments where possible. We included all patients seen in a tertiary care HF clinic from February 18 to March 13 (pre-Covid) and from March 16 to May 15 (post-COVID). We examined the volume of in-person and virtual visits and compared medication titration rates pre- and post-COVID.ResultsThe study cohort included 745 patients, mean age 60.7+/-15.3 years, 65.2% male, 80.9% Caucasian, 7.7% Hispanic/Latino. Of these, 227 patients were seen pre-COVID and 518 post-COVID. All appointments were in-person pre-COVID. After the change, only 18% of appointments were in-person while 82% were virtual. Outpatient volume decreased after March 15, but gradually increased, eventually to volumes that exceeded pre-COVID (Figure). Detailed results on medication titration are shown in Table. Diuretic titration took place in 33/227 (14.5%) of patients pre-COVID and 83/518 (16.0%) post-COVID (p=NS). Among 567 patients with HF with reduced ejection fraction (HFrEF), titration of guideline-directed medical therapy (GDMT) took place in 86/172 (50.0%) of patients pre-COVID and 159/395 (40.2%) post-COVID (p=0.03). Among the 395 HFrEF patients seen post-COVID, GDMT was titrated in 33/68 (48.5%) patients seen in person and 126/327 (38.5%) seen virtually - p=0.13. Barriers to medication titration in virtual visits were lack of blood pressure readings and lack of recent laboratory results.ConclusionTelehealth has become an essential method of outpatient care delivery for chronic HF. Once implemented, it offered efficiencies including improved access to the HF clinic thanks to higher throughput capacity compared to physical clinic space. However, we identified that GDMT titration took place less frequently than during in-person visits. Since it is anticipated that telehealth use will continue into the future, approaches to maximize GDMT in the absence of traditional direct physical contact with HF patients are needed. The COVID-19 pandemic disrupted the way care is delivered to patients with chronic conditions such as heart failure (HF). Many outpatient encounters are now conducted virtually via telehealth. Whether virtual visit for HF results in similar type of interventions as when the patient is seen in person is not known. Starting on March 15, 2020, all non-time sensitive outpatient in-person appointments at our institution were cancelled and transitioned to virtual appointments where possible. We included all patients seen in a tertiary care HF clinic from February 18 to March 13 (pre-Covid) and from March 16 to May 15 (post-COVID). We examined the volume of in-person and virtual visits and compared medication titration rates pre- and post-COVID. The study cohort included 745 patients, mean age 60.7+/-15.3 years, 65.2% male, 80.9% Caucasian, 7.7% Hispanic/Latino. Of these, 227 patients were seen pre-COVID and 518 post-COVID. All appointments were in-person pre-COVID. After the change, only 18% of appointments were in-person while 82% were virtual. Outpatient volume decreased after March 15, but gradually increased, eventually to volumes that exceeded pre-COVID (Figure). Detailed results on medication titration are shown in Table. Diuretic titration took place in 33/227 (14.5%) of patients pre-COVID and 83/518 (16.0%) post-COVID (p=NS). Among 567 patients with HF with reduced ejection fraction (HFrEF), titration of guideline-directed medical therapy (GDMT) took place in 86/172 (50.0%) of patients pre-COVID and 159/395 (40.2%) post-COVID (p=0.03). Among the 395 HFrEF patients seen post-COVID, GDMT was titrated in 33/68 (48.5%) patients seen in person and 126/327 (38.5%) seen virtually - p=0.13. Barriers to medication titration in virtual visits were lack of blood pressure readings and lack of recent laboratory results. Telehealth has become an essential method of outpatient care delivery for chronic HF. Once implemented, it offered efficiencies including improved access to the HF clinic thanks to higher throughput capacity compared to physical clinic space. However, we identified that GDMT titration took place less frequently than during in-person visits. Since it is anticipated that telehealth use will continue into the future, approaches to maximize GDMT in the absence of traditional direct physical contact with HF patients are needed.

Purpose A subset of end-stage heart failure (HF) patients on left ventricular assist device (LVAD) can significantly improve their native heart structure and function. Long-term stability of this cardiac improvement (CI) after LVAD weaning has not been well investigated. Methods We included chronic advanced non-ischemic cardiomyopathy patients (acute HF excluded) who were weaned from LVAD support based on predefined myocardial structural, functional and hemodynamic criteria. We defined "sustainable CI" after LVAD weaning as LVEF≥ 40% & LVEDD< 57mm. Regression analysis evaluated trends. Results Our cohort included 6 males and 6 females, mean age 33±12. Patients achieved LVAD weaning criteria after 532 [196, 2304] days of support. LVEF improved from 18±6 pre-implant to 46±10 % at LVAD explant (p<0.0001), LVEDD decreased from 65±7 to 46±6 mm (p<0.0001) and BNP decreased from 1438±1585 to 90±77 pg/ml (p<0.02). During a follow up post LVAD removal of 844 [15, 1241] days, we identified 2 groups, patients with sustainable (n=7) and with declining (n=5) CI (Figure). At the latest follow-up, the stable and declining groups differed with respect to LVEF (52 vs 17 %; p<0.0001), LVEDD (52 vs 65 mm; p=0.003) and BNP (58 vs 677 pg/ml; p=0.04). Quality of life assessment matched well with improvements in LV remodeling (Figure). The degree of CI pre-LVAD removal did not differ between the 2 groups and hence was not identified as a predictor of post weaning stability of CI. After LVAD weaning, 4/5 patients in the declining group had chronic systemic infection, drug abuse and HF medications therapy non-adherence, which likely affected negatively the stability of CI. A patient from this group was deceased due to HF recurrence. Conclusion In this single center report the long-term stability of CI after LVAD weaning appears to be encouraging. Larger and longer follow up clinical and translational studies are warranted to provide further clinical and mechanistic insights regarding factors associated with sustainable CI.

OBJECTIVES:To investigate the biologic relevance of cross-platform concordant changes in gene expression in intact human failing/hypertrophied ventricular myocardium undergoing reverse remodeling.BACKGROUND:Information is lacking on genes and networks involved in remodeled human LVs, and in the associated investigative best practices.METHODS:We measured mRNA expression in ventricular septal endomyocardial biopsies from 47 idiopathic dilated cardiomyopathy patients, at baseline and after 3-12 months of β-blocker treatment to effect left ventricular (LV) reverse remodeling as measured by ejection fraction (LVEF). Cross-platform gene expression change concordance was investigated in reverse remodeling Responders (R) and Nonresponders (NR) using 3 platforms (RT-qPCR, microarray, and RNA-Seq) and two cohorts (All 47 subjects (A-S) and a 12 patient "Super-Responder" (S-R) subset of A-S).RESULTS:For 50 prespecified candidate genes, in A-S mRNA expression 2 platform concordance (CcpT), but not single platform change, was directly related to reverse remodeling, indicating CcpT has biologic significance. Candidate genes yielded a CcpT (PCR/microarray) of 62% for Responder vs. Nonresponder (R/NR) change from baseline analysis in A-S, and ranged from 38% to 100% in S-R for PCR/microarray/RNA-Seq 2 platform comparisons. Global gene CcpT measured by microarray/RNA-Seq was less than for candidate genes, in S-R R/NR 17.5% vs. 38% (P = 0.036). For S-R global gene expression changes, both cross-cohort concordance (CccT) and CcpT yielded markedly greater values for an R/NR vs. an R-only analysis (by 22 fold for CccT and 7 fold for CcpT). Pathway analysis of concordant global changes for R/NR in S-R revealed signals for downregulation of multiple phosphoinositide canonical pathways, plus expected evidence of a β1-adrenergic receptor gene network including enhanced Ca2+ signaling.CONCLUSIONS:Two-platform concordant change in candidate gene expression is associated with LV biologic effects, and global expression concordant changes are best identified in an R/NR design that can yield novel information.

Abstract Background Predicting cardiac recovery (CR) in advanced heart failure (HF) patients before left ventricular assist device (LVAD) implantation remains challenging. This study sought to investigate whether CR after LVAD unloading can be predicted by cardiac functional and structural parameters together with clinical characteristics. Methods From 2008 to 2016, consecutive advanced chronic HF patients (N=347) supported with durable continuous-flow LVADs were prospectively evaluated. Patients with acute HF etiologies or without adequate post-LVAD follow up (<3 months) were excluded. A great variety of clinical characteristics were evaluated in the remaining 285 subjects. LVAD patients were phenotyped while on support, as CR Responders or Non Responders, based on published predefined echocardiographic criteria. Multivariable logistic regression was used to form the model and the Utah Cardiac Recovery (UCAR) score was created from the regression beta coefficients of the final model. Results CR occurred in 13.7% of patients. Univariate analysis showed that responders were more likely to be young, female, non-ischemic cardiomyopathy, with shorter HF symptoms duration and no prior cardiac surgery. They had lower blood urea nitrogen and were more likely to be on temporary mechanical support before LVAD. The multivariable UCAR model (AUC=0.755; p<0.001) predicted CR using 3 clinical parameters – Figure. Conclusion Univariate and multivariable predictors of CR include both modifiable and non-modifiable patient characteristics that are known prior to LVAD implantation. The UCAR score can serve as a practical tool for targeted patient selection to implement protocols that facilitate CR in the advanced HF patient subpopulation that is most likely to respond.

HomeCirculationVol. 140, No. 1Shock Team Approach in Refractory Cardiogenic Shock Requiring Short-Term Mechanical Circulatory Support Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBShock Team Approach in Refractory Cardiogenic Shock Requiring Short-Term Mechanical Circulatory SupportA Proof of Concept Iosif Taleb, MD, Antigone G. Koliopoulou, MD, Anwar Tandar, MD, Stephen H. McKellar, MD, MSc, Joseph E. Tonna, MD, Jose Nativi-Nicolau, MD, Miguel Alvarez Villela, MD, Frederick Welt, MD, Josef Stehlik, MD, MPH, Edward M. Gilbert, MD, Omar Wever-Pinzon, MD, Jack H. Morshedzadeh, MD, Elizabeth Dranow, PhD, Craig H. Selzman, MD, James C. Fang, MD and Stavros G. Drakos, MD, PhD Iosif TalebIosif Taleb Division of Cardiovascular Medicine (I.T., A.T., J.N-N., M.A.V., F.W., J.S., E.M.G., O.W-P., J.H.M., E.D., J.C.F., S.G.D.), University of Utah School of Medicine, Salt Lake City. Search for more papers by this author , Antigone G. KoliopoulouAntigone G. Koliopoulou Division of Cardiothoracic Surgery (A.G.K., S.H.M., J.E.T., C.H.S.), University of Utah School of Medicine, Salt Lake City. Cardiovascular Intensive Care Unit, University of Utah Health, Salt Lake City (A.G.K., A.T., S.H.M., J.E.T., J.N-N., F.W., J.S., E.M.G., O.W-P., J.H.M., C.H.S., J.C.F., S.G.D.). Search for more papers by this author , Anwar TandarAnwar Tandar Division of Cardiovascular Medicine (I.T., A.T., J.N-N., M.A.V., F.W., J.S., E.M.G., O.W-P., J.H.M., E.D., J.C.F., S.G.D.), University of Utah School of Medicine, Salt Lake City. Cardiovascular Intensive Care Unit, University of Utah Health, Salt Lake City (A.G.K., A.T., S.H.M., J.E.T., J.N-N., F.W., J.S., E.M.G., O.W-P., J.H.M., C.H.S., J.C.F., S.G.D.). Search for more papers by this author , Stephen H. McKellarStephen H. McKellar Division of Cardiothoracic Surgery (A.G.K., S.H.M., J.E.T., C.H.S.), University of Utah School of Medicine, Salt Lake City. Cardiovascular Intensive Care Unit, University of Utah Health, Salt Lake City (A.G.K., A.T., S.H.M., J.E.T., J.N-N., F.W., J.S., E.M.G., O.W-P., J.H.M., C.H.S., J.C.F., S.G.D.). Search for more papers by this author , Joseph E. TonnaJoseph E. Tonna Division of Cardiothoracic Surgery (A.G.K., S.H.M., J.E.T., C.H.S.), University of Utah School of Medicine, Salt Lake City. Cardiovascular Intensive Care Unit, University of Utah Health, Salt Lake City (A.G.K., A.T., S.H.M., J.E.T., J.N-N., F.W., J.S., E.M.G., O.W-P., J.H.M., C.H.S., J.C.F., S.G.D.). Search for more papers by this author , Jose Nativi-NicolauJose Nativi-Nicolau Division of Cardiovascular Medicine (I.T., A.T., J.N-N., M.A.V., F.W., J.S., E.M.G., O.W-P., J.H.M., E.D., J.C.F., S.G.D.), University of Utah School of Medicine, Salt Lake City. Cardiovascular Intensive Care Unit, University of Utah Health, Salt Lake City (A.G.K., A.T., S.H.M., J.E.T., J.N-N., F.W., J.S., E.M.G., O.W-P., J.H.M., C.H.S., J.C.F., S.G.D.). Search for more papers by this author , Miguel Alvarez VillelaMiguel Alvarez Villela Division of Cardiovascular Medicine (I.T., A.T., J.N-N., M.A.V., F.W., J.S., E.M.G., O.W-P., J.H.M., E.D., J.C.F., S.G.D.), University of Utah School of Medicine, Salt Lake City. Search for more papers by this author , Frederick WeltFrederick Welt Division of Cardiovascular Medicine (I.T., A.T., J.N-N., M.A.V., F.W., J.S., E.M.G., O.W-P., J.H.M., E.D., J.C.F., S.G.D.), University of Utah School of Medicine, Salt Lake City. Cardiovascular Intensive Care Unit, University of Utah Health, Salt Lake City (A.G.K., A.T., S.H.M., J.E.T., J.N-N., F.W., J.S., E.M.G., O.W-P., J.H.M., C.H.S., J.C.F., S.G.D.). Search for more papers by this author , Josef StehlikJosef Stehlik Division of Cardiovascular Medicine (I.T., A.T., J.N-N., M.A.V., F.W., J.S., E.M.G., O.W-P., J.H.M., E.D., J.C.F., S.G.D.), University of Utah School of Medicine, Salt Lake City. Cardiovascular Intensive Care Unit, University of Utah Health, Salt Lake City (A.G.K., A.T., S.H.M., J.E.T., J.N-N., F.W., J.S., E.M.G., O.W-P., J.H.M., C.H.S., J.C.F., S.G.D.). Search for more papers by this author , Edward M. GilbertEdward M. Gilbert Division of Cardiovascular Medicine (I.T., A.T., J.N-N., M.A.V., F.W., J.S., E.M.G., O.W-P., J.H.M., E.D., J.C.F., S.G.D.), University of Utah School of Medicine, Salt Lake City. Cardiovascular Intensive Care Unit, University of Utah Health, Salt Lake City (A.G.K., A.T., S.H.M., J.E.T., J.N-N., F.W., J.S., E.M.G., O.W-P., J.H.M., C.H.S., J.C.F., S.G.D.). Search for more papers by this author , Omar Wever-PinzonOmar Wever-Pinzon Division of Cardiovascular Medicine (I.T., A.T., J.N-N., M.A.V., F.W., J.S., E.M.G., O.W-P., J.H.M., E.D., J.C.F., S.G.D.), University of Utah School of Medicine, Salt Lake City. Cardiovascular Intensive Care Unit, University of Utah Health, Salt Lake City (A.G.K., A.T., S.H.M., J.E.T., J.N-N., F.W., J.S., E.M.G., O.W-P., J.H.M., C.H.S., J.C.F., S.G.D.). Search for more papers by this author , Jack H. MorshedzadehJack H. Morshedzadeh Division of Cardiovascular Medicine (I.T., A.T., J.N-N., M.A.V., F.W., J.S., E.M.G., O.W-P., J.H.M., E.D., J.C.F., S.G.D.), University of Utah School of Medicine, Salt Lake City. Cardiovascular Intensive Care Unit, University of Utah Health, Salt Lake City (A.G.K., A.T., S.H.M., J.E.T., J.N-N., F.W., J.S., E.M.G., O.W-P., J.H.M., C.H.S., J.C.F., S.G.D.). Search for more papers by this author , Elizabeth DranowElizabeth Dranow Division of Cardiovascular Medicine (I.T., A.T., J.N-N., M.A.V., F.W., J.S., E.M.G., O.W-P., J.H.M., E.D., J.C.F., S.G.D.), University of Utah School of Medicine, Salt Lake City. Search for more papers by this author , Craig H. SelzmanCraig H. Selzman Division of Cardiothoracic Surgery (A.G.K., S.H.M., J.E.T., C.H.S.), University of Utah School of Medicine, Salt Lake City. Cardiovascular Intensive Care Unit, University of Utah Health, Salt Lake City (A.G.K., A.T., S.H.M., J.E.T., J.N-N., F.W., J.S., E.M.G., O.W-P., J.H.M., C.H.S., J.C.F., S.G.D.). Search for more papers by this author , James C. FangJames C. Fang Division of Cardiovascular Medicine (I.T., A.T., J.N-N., M.A.V., F.W., J.S., E.M.G., O.W-P., J.H.M., E.D., J.C.F., S.G.D.), University of Utah School of Medicine, Salt Lake City. Cardiovascular Intensive Care Unit, University of Utah Health, Salt Lake City (A.G.K., A.T., S.H.M., J.E.T., J.N-N., F.W., J.S., E.M.G., O.W-P., J.H.M., C.H.S., J.C.F., S.G.D.). Search for more papers by this author and Stavros G. DrakosStavros G. Drakos Stavros G. Drakos, MD, PhD, Division of Cardiovascular Medicine & Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah School of Medicine, 30 North 1900 East, Room 4A150, Salt Lake City, UT 84132. Email E-mail Address: [email protected] Division of Cardiovascular Medicine (I.T., A.T., J.N-N., M.A.V., F.W., J.S., E.M.G., O.W-P., J.H.M., E.D., J.C.F., S.G.D.), University of Utah School of Medicine, Salt Lake City. Cardiovascular Intensive Care Unit, University of Utah Health, Salt Lake City (A.G.K., A.T., S.H.M., J.E.T., J.N-N., F.W., J.S., E.M.G., O.W-P., J.H.M., C.H.S., J.C.F., S.G.D.). Search for more papers by this author Originally published1 Jul 2019https://doi.org/10.1161/CIRCULATIONAHA.119.040654Circulation. 2019;140:98–100Despite efforts to improve treatment of refractory cardiogenic shock (rCS), prognosis remains poor. Multidisciplinary Shock Teams have been proposed as a strategy to streamline care delivery and improve outcomes despite the lack of strong evidence.1–5 This study sought to determine the feasibility and efficacy of the Shock Team approach for rCS at our tertiary care institution.The Utah Cardiac Recovery Shock Team was established in April 2015 to evaluate patients in acute cardiogenic shock (CS) with a standardized comprehensive multidisciplinary assessment. From April 2015 to August 2018, we prospectively identified 123 consecutive patients with rCS, treated with mechanical circulatory support (MCS), using the Team approach. We compared this cohort with the immediately preceding 121 rCS patients, treated with MCS, but without Shock Team evaluation (control cohort) in a retrospective fashion. Postcardiotomy patients and those requiring central extracorporeal membrane oxygenation were excluded. The study was approved by the University of Utah’s Institutional Review Board, and participants gave written informed consent.The Shock Team comprises a heart failure cardiologist, a heart failure cardiothoracic surgeon, an interventional cardiologist, and a Cardiovascular Intensive Care Unit attending physician. Once activated, all Team members participate in the decisions surrounding patient management and therapeutic options. Activations after hours or on weekends do not automatically bring all the on-call staff in; however, it initiates a discussion between the involved parties. The heart failure cardiologist performs the initial screening when clinical suspicion of CS exists and serves as the central hub coordinating the whole process. Once a patient is deemed to have CS, empirical medical therapy is initiated and arterial line placement, right heart catheterization, and coronary revascularization ensue as warranted, based on the clinical scenario. If, despite optimal medical therapy, the patient remains hypotensive, and cardiac index is <2.2 L/(min · m2) and pulmonary capillary wedge pressure or left ventricular end-diastolic pressure is >15 mm Hg, or the patient has clinical signs of impaired end-organ perfusion, then escalation to short-term MCS is considered, and device selection is made by consensus of all Team members. The patient continues to be managed by the Team until resolution of CS, or until a decision is made to deescalate care respecting the patient’s or family’s wishes.The primary end point was 30-day all-cause mortality. Secondary end points included shock-to-support time (as a surrogate of the feasibility of the Team approach), in-hospital survival, length of MCS support, escalation to surgically implantable durable ventricular assist device, and length of intensive care unit stay.The baseline patient characteristics are presented in the Figure (A). After institution of the Shock Team, the primary outcome of 30-day all-cause mortality decreased in the univariate analysis and this effect persisted after controlling for relevant confounders (hazard ratio: 0.61 [95% CI, 0.41–0.93]; Figure [B]). The multivariate modeling also identified acute coronary syndrome–related CS (HR: 2.76 [95% CI, 1.69–4.50]), lactate level (HR: 1.14 [95% CI, 1.10–1.18]), and acute kidney injury (HR: 2.12 [95% CI, 1.36–3.32]) as independent risk factors at the time of MCS institution, associated with 30-day mortality. Of note, device type was not associated with a survival benefit. Sensitivity analysis suggests no interaction on the effect of the Shock Team on 30-day mortality when examining the CS cause (ST-segment–elevation myocardial infarction, non–ST-segment–elevation myocardial infarction, acute decompensated heart failure, and other), the location of the onset of CS (ie, referring versus University of Utah hospital), and the presence of cardiopulmonary resusitation. A time series analysis to address a time trend was not possible due to few time points of data to reliably fit a model. In-hospital survival also favored the Shock Team (61.0% versus 47.9%; P=0.041). The secondary outcome of Shock-to-Support time was comparable between the Shock Team and control (19±5 versus 25±8 hours; P=0.52). Likewise, the mean length of MCS support was similar between the groups (121±13 versus 104±16 hours). Among the 133 (54.5%) survivors to hospital discharge, 99 experienced improvement leading to MCS weaning, whereas 34 were bridged to a surgically implantable durable left ventricular assist device. The overall mean intensive care unit stay was similar between the groups. No significant differences were seen between the groups in the rates of major bleeding, cerebrovascular accidents, rates of hemolysis and major vascular complication leading to surgical vascular repair, fasciotomy, or amputation.Download figureDownload PowerPointFigure. Shock Team approach appears to be feasible and beneficial in the management of refractory cardiogenic shock.A, Baseline characteristics of study population. Data expressed as mean±SE or n (%). B, Shock Team algorithm and adjusted Kaplan-Meier 30-day survival. ACS indicates acute coronary syndrome; BP, blood pressure; CCO, continuous cardiac output; CI, cardiac index; COPD, chronic obstructive pulmonary disease; CPR, cardiopulmonary resuscitation; CT, cardiothoracic; CVICU, cardiovascular intensive care unit; HF, heart failure; HFrEF, heart failure reduced ejection fraction; IABP, intra-aortic balloon pump; LHC, left heart catheterization; LVEDP, left ventricular end-diastolic pressure; LVEF, left ventricular ejection fraction; MCS, mechanical circulatory support; PCI, percutaneous coronary intervention; PCWP, pulmonary capillary wedge pressure; RAP, right atrial pressure; RHC, right heart catheterization; STEMI, ST-segment–elevation myocardial infarction; s-t MCS, short-term mechanical circulatory support; SVR, systemic vascular resistance; UoU, University of Utah hospital; and VA-ECMO, veno-arterial extracorporeal membrane oxygenation. *Criteria for considering s-t MCS: low systemic blood pressure (SBP) <90 mm Hg OR mean arterial pressure <50 mm Hg for >30 mins OR needed IV vasoactive agents infusion to maintain SBP>90 mm Hg or MAP>50 mm Hg, plus 1 of the following: PCWP or LVEDP>15 mm Hg and CI<2.2 L/(min · m2) OR signs of pulmonary edema, OR impaired end-organ perfusion, defined as altered mental status; or cold, clammy skin and extremities; or urine output <30 mL/h.In this study, the multidisciplinary Shock Team approach for the treatment of rCS decreased in-hospital and 30-day all-cause mortality. This strategy may constitute an opportunity to improve the management of this condition, for which multiple interventions and devices have failed to show a survival benefit. Importantly, our finding on the secondary outcome of Shock-to-Support time addresses the concern of delaying care with increasing the number of providers comprising the Shock Team. Indeed, a multidisciplinary approach did not delay the implementation of critical decisions, while ensuring appropriate level of support and planning in case escalation was needed. After 4 years of implementation in our institution, the Shock Team initiative remains fully operational, suggesting the sustainability of such programs in clinical practice. These encouraging findings warrant validation by prospective large-scale randomized controlled trials.AcknowledgmentsWe are thankful to Greg Stoddard MPH, MBA, for statistical support. Also, we are thankful to ABIOMED for providing the required funding for the first year of our prospective Cardiogenic Shock Registry.Sources of FundingFinancial support to Dr Drakos was provided by the American Heart Association Heart Failure Strategically Focused Research Network, 16SFRN29020000, NHLBI R01 HL135121-01, NHLBI R01 HL132067-01A1, and the Nora Eccles Treadwell Foundation, Salt Lake City, UT. ABIOMED funded the first year of our prospective registry.DisclosuresDr Drakos is a consultant to Abbott. The other authors report no conflicts.FootnotesData sharing: The data that support the findings of this study are available from the corresponding author upon reasonable request.Stavros G. Drakos, MD, PhD, Division of Cardiovascular Medicine & Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah School of Medicine, 30 North 1900 East, Room 4A150, Salt Lake City, UT 84132. Email stavros.[email protected]utah.eduReferences1. Tchantchaleishvili V, Hallinan W, Massey HT. Call for organized statewide networks for management of acute myocardial infarction-related cardiogenic shock.JAMA Surg. 2015; 150:1025–1026. doi: 10.1001/jamasurg.2015.2412CrossrefMedlineGoogle Scholar2. van Diepen S, Katz JN, Albert NM, Henry TD, Jacobs AK, Kapur NK, Kilic A, Menon V, Ohman EM, Sweitzer NK, Thiele H, Washam JB, Cohen MG; American Heart Association Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; and Mission: Lifeline. Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association.Circulation. 2017; 136:e232–e268. doi: 10.1161/CIR.0000000000000525LinkGoogle Scholar3. Rab T, Ratanapo S, Kern KB, Basir MB, McDaniel M, Meraj P, King SB, O’Neill W. Cardiac shock care centers: JACC review topic of the week.J Am Coll Cardiol. 2018; 72:1972–1980. doi: 10.1016/j.jacc.2018.07.074CrossrefMedlineGoogle Scholar4. Takayama H, Truby L, Koekort M, Uriel N, Colombo P, Mancini DM, Jorde UP, Naka Y. Clinical outcome of mechanical circulatory support for refractory cardiogenic shock in the current era.J Heart Lung Transplant. 2013; 32:106–111. doi: 10.1016/j.healun.2012.10.005CrossrefMedlineGoogle Scholar5. Tehrani BN, Truesdell AG, Sherwood MW, Desai S, Tran HA, Epps KC, Singh R, Psotka M, Shah P, Cooper LB, Rosner C, Raja A, Barnett SD, Saulino P, deFilippi CR, Gurbel PA, Murphy CE, O’Connor CM. Standardized team-based care for cardiogenic shock.J Am Coll Cardiol. 2019; 73:1659–1669. doi: 10.1016/j.jacc.2018.12.084CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Owyang C, Donnat C, Brodie D, Gershengorn H, Hua M, Qadir N and Tonna J (2022) Similarities in extracorporeal membrane oxygenation management across intensive care unit types in the United States: An analysis of the Extracorporeal Life Support Organization Registry, Artificial Organs, 10.1111/aor.14193, 46:7, (1369-1381), Online publication date: 1-Jul-2022. Sinha S, Rosner C, Tehrani B, Maini A, Truesdell A, Lee S, Bagchi P, Cameron J, Damluji A, Desai M, Desai S, Epps K, deFilippi C, Flanagan M, Genovese L, Moukhachen H, Park J, Psotka M, Raja A, Shah P, Sherwood M, Singh R, Tang D, Young K, Welch T, O’Connor C and Batchelor W (2022) Cardiogenic Shock From Heart Failure Versus Acute Myocardial Infarction: Clinical Characteristics, Hospital Course, and 1-Year Outcomes, Circulation: Heart Failure, 15:6, (e009279), Online publication date: 1-Jun-2022. Fried J, Griffin J, Masoumi A, Clerkin K, Witer L, Topkara V, Karmpaliotis D, Rabbani L, Colombo P, Yuzefpolskaya M, Takayama H, Naka Y, Kirtane A, Brodie D, Sayer G, Uriel N, Takeda K and Garan A (2022) Predictors of Survival and Ventricular Recovery Following Acute Myocardial Infarction Requiring Extracorporeal Membrane Oxygenation Therapy, ASAIO Journal, 10.1097/MAT.0000000000001570, 68:6, (800-807), Online publication date: 1-Jun-2022. Bloom J, Andrew E, Nehme Z, Beale A, Dawson L, Shi W, Vriesendorp P, Fernando H, Noaman S, Cox S, Stephenson M, Anderson D, Chan W, Kaye D, Smith K and Stub D (2022) Gender Disparities in Cardiogenic Shock Treatment and Outcomes, The American Journal of Cardiology, 10.1016/j.amjcard.2022.04.047, Online publication date: 1-Jun-2022. Krause T and Rieth A (2022) Aktuelle Klassifikation und hämodynamisches Profil bei kardiogenem SchockUpdated classification and hemodynamics in cardiogenic shock, Zeitschrift für Herz-,Thorax- und Gefäßchirurgie, 10.1007/s00398-022-00507-9, 36:3, (158-163), Online publication date: 1-Jun-2022. Masiero G, Cardaioli F and Tarantini G (2022) Mechanical circulatory support in cardiogenic shock: a critical appraisal, Expert Review of Cardiovascular Therapy, 10.1080/14779072.2022.2078702, (1-12) Heidenreich P, Bozkurt B, Aguilar D, Allen L, Byun J, Colvin M, Deswal A, Drazner M, Dunlay S, Evers L, Fang J, Fedson S, Fonarow G, Hayek S, Hernandez A, Khazanie P, Kittleson M, Lee C, Link M, Milano C, Nnacheta L, Sandhu A, Stevenson L, Vardeny O, Vest A and Yancy C (2022) 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines, Circulation, 145:18, (e895-e1032), Online publication date: 3-May-2022. Brusca S, Caughron H, Njoroge J, Cheng R, O’Brien C and Barnett C (2022) The shock team: a multidisciplinary approach to early patient phenotyping and appropriate care escalation in cardiogenic shock, Current Opinion in Cardiology, 10.1097/HCO.0000000000000967, 37:3, (241-249), Online publication date: 1-May-2022. Heidenreich P, Bozkurt B, Aguilar D, Allen L, Byun J, Colvin M, Deswal A, Drazner M, Dunlay S, Evers L, Fang J, Fedson S, Fonarow G, Hayek S, Hernandez A, Khazanie P, Kittleson M, Lee C, Link M, Milano C, Nnacheta L, Sandhu A, Stevenson L, Vardeny O, Vest A and Yancy C (2022) 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure, Journal of the American College of Cardiology, 10.1016/j.jacc.2021.12.012, 79:17, (e263-e421), Online publication date: 1-May-2022. Shah T, Kapadia S, Lansky A and Grines C (2022) ST-Segment Elevation Myocardial Infarction: Sex Differences in Incidence, Etiology, Treatment, and Outcomes, Current Cardiology Reports, 10.1007/s11886-022-01676-7, 24:5, (529-540), Online publication date: 1-May-2022. Vallabhajosyula S, Katz J and Menon V (2022) Quantification of Vasoactive Medications and the “Pharmaco-Mechanical Continuum” in Cardiogenic Shock, Circulation: Heart Failure, 15:4, (e008736), Online publication date: 1-Apr-2022. Tehrani B, Damluji A and Batchelor W Acute Myocardial Infarction and Cardiogenic Shock Interventional Approach to Management in the Cardiac Catheterization Laboratories, Current Cardiology Reviews, 10.2174/1573403X17666211125090929, 18:2 Scolari F, Trott G, Schneider D, Goldraich L, Frederico Tonietto T, Moura L, Bertoldi E, Rover M, Wolf J, Souza D, Clausell N, Polanczyk C, Rohde L, Rosa R and Wainstein R (2022) Cardiogenic shock treated with temporary mechanical circulatory support in Brazil: The effect of learning curve, The International Journal of Artificial Organs, 10.1177/03913988211070841, 45:3, (292-300), Online publication date: 1-Mar-2022. Tehrani B, Drakos S, Billia F, Batchelor W, Luk A, Stelling K, Tonna J, Rosner C, Hanff T, Rao V, Brozzi N and Baran D (2022) The Multicenter Collaborative to Enhance Biologic Understanding, Quality, and Outcomes in Cardiogenic Shock (VANQUISH Shock): Rationale and Design, Canadian Journal of Cardiology, 10.1016/j.cjca.2022.03.005, Online publication date: 1-Mar-2022. Hernandez-Montfort J, Miranda D, Randhawa V, Sleiman J, de Armas Y, Lewis A, Taimeh Z, Alvarez P, Cremer P, Perez-Villa B, Navas V, Hakemi E, Velez M, Hernandez-Mejia L, Sheffield C, Brozzi N, Cubeddu R, Navia J and Estep J (2022) Hemodynamic-based Assessment and Management of Cardiogenic Shock, US Cardiology Review, 10.15420/usc.2021.12, 16 Shankar A, Gurumurthy G, Sridharan L, Gupta D, Nicholson W, Jaber W and Vallabhajosyula S (2022) A Clinical Update on Vasoactive Medication in the Management of Cardiogenic Shock, Clinical Medicine Insights: Cardiology, 10.1177/11795468221075064, 16, (117954682210750), Online publication date: 1-Jan-2022. Quien M, Thomas A, Ludmir J and Miller P (2022) Staffing models in the cardiac intensive care unit, Current Opinion in Critical Care, 10.1097/MCC.0000000000000958, Publish Ahead of Print Hsu S, Fang J and Borlaug B (2022) Hemodynamics for the Heart Failure Clinician: A State-of-the-Art Review, Journal of Cardiac Failure, 10.1016/j.cardfail.2021.07.012, 28:1, (133-148), Online publication date: 1-Jan-2022. Ponamgi S, Maqsood M, Sundaragiri P, DelCore M, Kanmanthareddy A, Jaber W, Nicholson W and Vallabhajosyula S (2021) Pulmonary artery catheterization in acute myocardial infarction complicated by cardiogenic shock: A review of contemporary literature, World Journal of Cardiology, 10.4330/wjc.v13.i12.720, 13:12, (720-732), Online publication date: 26-Dec-2022. Proudfoot A, Kalakoutas A, Meade S, Griffiths M, Basir M, Burzotta F, Chih S, Fan E, Haft J, Ibrahim N, Kruit N, Lim H, Morrow D, Nakata J, Price S, Rosner C, Roswell R, Samaan M, Samsky M, Thiele H, Truesdell A, van Diepen S, Voeltz M and Irving P (2021) Contemporary Management of Cardiogenic Shock: A RAND Appropriateness Panel Approach, Circulation: Heart Failure, 14:12, Online publication date: 1-Dec-2021. Basir M, Pinto D, Ziaeian B, Khandelwal A, Cowger J, Suh W and Althouse A (2021) Mechanical circulatory support in acute myocardial infarction and cardiogenic shock: Challenges and importance of randomized control trials, Catheterization and Cardiovascular Interventions, 10.1002/ccd.29593, 98:7, (1264-1274), Online publication date: 1-Dec-2021. Marashly Q, Taleb I, Kyriakopoulos C, Dranow E, Jones T, Tandar A, Overton S, Tonna J, Stoddard K, Wever‐Pinzon O, Kemeyou L, Koliopoulou A, Shah K, Nourian K, Richins T, Burnham T, Welt F, McKellar S, Nativi‐Nicolau J and Drakos S (2021) Predicting mortality in cardiogenic shock secondary to ACS requiring short‐term mechanical circulatory support: The ACS‐MCS score , Catheterization and Cardiovascular Interventions, 10.1002/ccd.29581, 98:7, (1275-1284), Online publication date: 1-Dec-2021. Samsky M, Morrow D, Proudfoot A, Hochman J, Thiele H and Rao S (2021) Cardiogenic Shock After Acute Myocardial Infarction, JAMA, 10.1001/jama.2021.18323, 326:18, (1840), Online publication date: 9-Nov-2021. Warren A, Rosner C, Gattani R, Truesdell A and Proudfoot A (2021) Cardiogenic Shock: Protocols, Teams, Centers, and Networks, US Cardiology Review, 10.15420/usc.2021.10, 15 Schrage B, Zeymer U, Montalescot G, Windecker S, Serpytis P, Vrints C, Stepinska J, Savonitto S, Oldroyd K, Desch S, Fuernau G, Huber K, Noc M, Schneider S, Ouarrak T, Blankenberg S, Thiele H and Clemmensen P (2021) Impact of Center Volume on Outcomes in Myocardial Infarction Complicated by Cardiogenic Shock: A CULPRIT‐SHOCK Substudy, Journal of the American Heart Association, 10:20, Online publication date: 19-Oct-2021.Osman M, Syed M, Patel B, Munir M, Kheiri B, Caccamo M, Sokos G, Balla S, Basir M, Kapur N, Mamas M and Bianco C (2021) Invasive Hemodynamic Monitoring in Cardiogenic Shock Is Associated With Lower In‐Hospital Mortality, Journal of the American Heart Association, 10:18, Online publication date: 21-Sep-2021. Alvarez Villela M, Clark R, William P, Sims D and Jorde U (2021) Systems of Care in Cardiogenic Shock, Frontiers in Cardiovascular Medicine, 10.3389/fcvm.2021.712594, 8 Papolos A, Kenigsberg B, Berg D, Alviar C, Bohula E, Burke J, Carnicelli A, Chaudhry S, Drakos S, Gerber D, Guo J, Horowitz J, Katz J, Keeley E, Metkus T, Nativi-Nicolau J, Snell J, Sinha S, Tymchak W, Van Diepen S, Morrow D and Barnett C (2021) Management and Outcomes of Cardiogenic Shock in Cardiac ICUs With Versus Without Shock Teams, Journal of the American College of Cardiology, 10.1016/j.jacc.2021.07.044, 78:13, (1309-1317), Online publication date: 1-Sep-2021. Osman M, Syed M, Patibandla S, Sulaiman S, Kheiri B, Shah M, Bianco C, Balla S and Patel B (2021) Fifteen‐Year Trends in Incidence of Cardiogenic Shock Hospitalization and In‐Hospital Mortality in the United States, Journal of the American Heart Association, 10:15, Online publication date: 3-Aug-2021. Berg D, Bohula E and Morrow D (2021) Epidemiology and causes of cardiogenic shock, Current Opinion in Critical Care, 10.1097/MCC.0000000000000845, 27:4, (401-408), Online publication date: 1-Aug-2021. Sperry A, Williams M, Atluri P, Szeto W, Cevasco M, Bermudez C, Acker M and Ibrahim M (2021) The Surgeon’s Role in Cardiogenic Shock, Current Heart Failure Reports, 10.1007/s11897-021-00514-1, 18:4, (240-251), Online publication date: 1-Aug-2021. Kunkel K, Fuller B and Basir M (2021) Management of Cardiogenic Shock in Patients with Acute Myocardial Infarction, Interventional Cardiology Clinics, 10.1016/j.iccl.2021.03.006, 10:3, (345-357), Online publication date: 1-Jul-2021. Sturm R, Jones T, Youngquist S and Shah R (2021) Regional Systems of Care in ST Elevation Myocardial Infarction, Interventional Cardiology Clinics, 10.1016/j.iccl.2021.03.001, 10:3, (281-291), Online publication date: 1-Jul-2021. Singh S, Witer L, Kaku Y, Masoumi A, Fried J, Yuzefpolskaya M, Colombo P, Sayer G, Uriel N, Naka Y, Takayama H and Takeda K (2021) Temporary surgical ventricular assist device for treatment of acute myocardial infarction and refractory cardiogenic shock in the percutaneous device era, Journal of Artificial Organs, 10.1007/s10047-020-01236-2, 24:2, (199-206), Online publication date: 1-Jun-2021. Henry T, Tomey M, Tamis-Holland J, Thiele H, Rao S, Menon V, Klein D, Naka Y, Piña I, Kapur N and Dangas G (2021) Invasive Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock: A Scientific Statement From the American Heart Association, Circulation, 143:15, (e815-e829), Online publication date: 13-Apr-2021. Lemor A, Ya’qoub L and Basir M (2021) Mechanical Circulatory Support in Acute Myocardial Infarction and Cardiogenic Shock, Interventional Cardiology Clinics, 10.1016/j.iccl.2020.12.005, 10:2, (169-184), Online publication date: 1-Apr-2021. Schrage B, Becher P, Goßling A, Savarese G, Dabboura S, Yan I, Beer B, Söffker G, Seiffert M, Kluge S, Kirchhof P, Blankenberg S and Westermann D (2021) Temporal trends in incidence, causes, use of mechanical circulatory support and mortality in cardiogenic shock, ESC Heart Failure, 10.1002/ehf2.13202, 8:2, (1295-1303), Online publication date: 1-Apr-2021. Moghaddam N, Diepen S, So D, Lawler P and Fordyce C (2021) Cardiogenic shock teams and centres: a contemporary review of multidisciplinary care for cardiogenic shock, ESC Heart Failure, 10.1002/ehf2.13180, 8:2, (988-998), Online publication date: 1-Apr-2021. Omer M, Exaire J, Jentzer J, Sandoval Y, Singh M, Cagin C, Elgendy I and Tak T (2021) Management of ST-Elevation Myocardial Infarction in High-Risk Settings, International Journal of Angiology, 10.1055/s-0041-1723941, 30:01, (053-066), Online publication date: 1-Mar-2021. Ya’qoub L, Lemor A, Dabbagh M, O’Neill W, Khandelwal A, Martinez S, Ibrahim N, Grines C, Voeltz M and Basir M (2021) Racial, Ethnic, and Sex Disparities in Patients With STEMI and Cardiogenic Shock, JACC: Cardiovascular Interventions, 10.1016/j.jcin.2021.01.003, 14:6, (653-660), Online publication date: 1-Mar-2021. Gong F, Vaitenas I, Malaisrie S and Maganti K (2021) Mechanical Complications of Acute Myocardial Infarction, JAMA Cardiology, 10.1001/jamacardio.2020.3690, 6:3, (341), Online publication date: 1-Mar-2021. Díaz Molina B, González Costello J and Barge-Caballero E (2021) Código shock en España. El próximo salto de calidad en la asistencia cardiológica ya está aquí, Revista Española de Cardiología, 10.1016/j.recesp.2020.07.026, 74:1, (5-7), Online publication date: 1-Jan-2021. Hernández-Pérez F, Álvarez-Avelló J, Forteza A, Gómez-Bueno M, González A, López-Ibor J, Silva-Melchor L, Goicolea J, Martín C, Iranzo R, Goirigolzarri-Artaza J, Escudier-Villa J, Ortega-Marcos J, Oteo-Domínguez J, Herrero-Cano Á, Moñivas V, Mingo-Santos S, Villar S, Jiménez-Blanco M, Coscia C, Serrano-Fiz S, Alonso-Pulpón L and Segovia-Cubero J (2021) Resultados iniciales de un programa multidisciplinario de atención a pacientes en shock cardiogénico en red, Revista Española de Cardiología, 10.1016/j.recesp.2020.01.019, 74:1, (33-43), Online publication date: 1-Jan-2021. Díaz Molina B, González Costello J and Barge-Caballero E (2021) The shock code in Spain. The next quality leap in cardiological care is here, Revista Española de Cardiología (English Edition), 10.1016/j.rec.2020.07.017, 74:1, (5-7), Online publication date: 1-Jan-2021. Hernández-Pérez F, Álvarez-Avelló J, Forteza A, Gómez-Bueno M, González A, López-Ibor J, Silva-Melchor L, Goicolea J, Martín C, Iranzo R, Goirigolzarri-Artaza J, Escudier-Villa J, Ortega-Marcos J, Oteo-Domínguez J, Herrero-Cano Á, Moñivas V, Mingo-Santos S, Villar S, Jiménez-Blanco M, Coscia C, Serrano-Fiz S, Alonso-Pulpón L and Segovia-Cubero J (2021) Initial outcomes of a multidisciplinary network for the care of patients with cardiogenic shock, Revista Española de Cardiología (English Edition), 10.1016/j.rec.2020.03.010, 74:1, (33-43), Online publication date: 1-Jan-2021. García-Pinilla J, García-Cosío Carmena M, Farrero-Torres M, Recio-Mayoral A and González-Costello J (2021) Selección de lo mejor del año 2020 en insuficiencia cardiaca, REC: CardioClinics, 10.1016/j.rccl.2020.11.009, 56, (66-71), Online publication date: 1-Jan-2021. Viana-Tejedor A, Uribarri A, Martínez Losas P, Andrea R, Corbí Pascual M, Jorge Pérez P, Ariza Solé A and López de Sá E (2021) Selección de lo mejor del año 2020 en cardiopatía isquémica y cuidados críticos cardiológicos, REC: CardioClinics, 10.1016/j.rccl.2020.10.011, 56, (35-40), Online publication date: 1-Jan-2021. Gibbs D, Eusebio C, Sanders J, Rosner C, Tehrani B, Truesdell A, O'Brien B, Finney S and Proudfoot A (2021) Clinician Perceptions of the Impact of a Shock Team Approach in the Management of Cardiogenic Shock: A Qualitative Study, Cardiovascular Revascularization Medicine, 10.1016/j.carrev.2020.06.011, 22, (78-83), Online publication date: 1-Jan-2021. Brilakis E (2021) Complex patient subgroups Manual of Percutaneous Coronary Interventions, 10.1016/B978-0-12-819367-9.00024-X, (397-406), . Wang J, Lu D, MHS , Feldman D, McCullough S, Goyal P, Karas M, Sobol I, Horn E, Kim L and Krishnan U (2020) Outcomes of Hospitalizations for Cardiogenic Shock at Left Ventricular Assist Device Versus Non–Left Ventricular Assist Device Centers, Journal of the American Heart Association, 9:23, Online publication date: 1-Dec-2020. Baran D, Long A, Badiye A and Stelling K (2020) Prospective validation of the SCAI shock classification: Single center analysis , Catheterization and Cardiovascular Interventions, 10.1002/ccd.29319, 96:7, (1339-1347), Online publication date: 1-Dec-2020. Tehrani B, Truesdell A, Psotka M, Rosner C, Singh R, Sinha S, Damluji A and Batchelor W (2020) A Standardized and Comprehensive Approach to the Management of Cardiogenic Shock, JACC: Heart Failure, 10.1016/j.jchf.2020.09.005, 8:11, (879-891), Online publication date: 1-Nov-2020. Fang J and Jones T (2020) Can a Pulmonary Artery Catheter Improve Outcomes in Cardiogenic Shock?, JACC: Heart Failure, 10.1016/j.jchf.2020.08.013, 8:11, (914-916), Online publication date: 1-Nov-2020. Tehrani B, Basir M and Kapur N (2020) Acute myocardial infarction and cardiogenic shock: Should we unload the ventricle before percutaneous coronary intervention?, Progress in Cardiovascular Diseases, 10.1016/j.pcad.2020.09.001, 63:5, (607-622), Online publication date: 1-Sep-2020. Eschenroeder L, Nguyen V, Neradilek M, Li S and Dardas T (2020) Patterns of Hospital Bypass and Interhospital Transfer Among Patients With Heart Failure, Journal of Cardiac Failure, 10.1016/j.cardfail.2020.04.015, 26:9, (762-768), Online publication date: 1-Sep-2020. Anstey D, Givens R, Clerkin K, Fried J, Kalcheva N, Kumaraiah D, Masoumi A, O'Connor D, Rosner G, Wasson L, Hammond J, Kirtane A, Uriel N, Schwartz A, Rabbani L and Abdalla M (2020) The cardiac intensive care unit and the cardiac intensivist during the COVID-19 surge in New York City, American Heart Journal, 10.1016/j.ahj.2020.06.018, 227, (74-81), Online publication date: 1-Sep-2020. Alvarez P and Hernandez-Montfort J (2020) Shock Team Approaches in Managing Cardiogenic Shock—Intersection Between Critical Care and Advanced Heart Failure and Transplant Cardiology, Current Treatment Options in Cardiovascular Medicine, 10.1007/s11936-020-00820-2, 22:9, Online publication date: 1-Sep-2020. Schrage B, Dabboura S, Yan I, Hilal R, Neumann J, Sörensen N, Goßling A, Becher P, Grahn H, Wagner T, Seiffert M, Kluge S, Reichenspurner H, Blankenberg S and Westermann D (2020) Application of the SCAI classification in a cohort of patients with cardiogenic shock, Catheterization and Cardiovascular Interventions, 10.1002/ccd.28707, 96:3, Online publication date: 1-Sep-2020. Luk A, Wang V, Almazroa L, Foroutan F, Huebener N, Hillyer A, Billia F, Ross H and Overgaard C (2020) Management of Acute Decompensated Heart Failure in the Cardiac Intensive Care Unit: The Importance of Co-management With a Heart Failure Specialist, CJC Open, 10.1016/j.cjco.2020.02.010, 2:4, (229-235), Online publication date: 1-Jul-2020. Schrage B, Weimann J, Dabboura S, Yan I, Hilal R, Becher P, Seiffert M, Bernhardt A, Kluge S, Reichenspurner H, Blankenberg S and Westermann D (2020) Patient Characteristics, Treatment and Outcome in Non-Ischemic vs. Ischemic Cardiogenic Shock, Journal of Clinical Medicine, 10.3390/jcm9040931, 9:4, (931) Kim D (2020) Mechanical Circulatory Support in Cardiogenic Shock: Shock Team or Bust?, Canadian Journal of Cardiology, 10.1016/j.cjca.2019.11.001, 36:2, (197-204), Online publication date: 1-Feb-2020. Tandar A and Drakos S (2019) Cardiogenic shock in aortic stenosis patients: Balancing between complexity and simplicity, Hellenic Journal of Cardiology, 10.1016/j.hjc.2019.06.002, 60:3, (182-184), Online publication date: 1-May-2019. July 2, 2019Vol 140, Issue 1 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.119.040654PMID: 31549877 Originally publishedJuly 1, 2019 Keywordsmyocardial infarctionintensive care unitssurvival analysisheart failureshock, cardiogenicPDF download Advertisement SubjectsCardiomyopathyCardiopulmonary Resuscitation and Emergency Cardiac CareClinical StudiesHeart FailureMyocardial Infarction

ObjectivesOur goal was to identify conventional, deformational, and rotational echocardiographic parameters that could differentiate heart failure patients with preserved ejection fraction secondary to amyloidosis (HFpEF-amyloid) vs. heart failure patients with preserved ejection fraction without amyloidosis (HFpEF).IntroductionHFpEF represents a heterogeneous clinical syndrome. Studies have shown that a substantial number of HFpEF patients have cardiac amyloidosis. Early identification of cardiac amyloidosis with a routine imaging modality such as echocardiography could improve disease management and outcomes.Methods and ResultsMedical records of patients with HFpEF-amyloid and HFpEF were reviewed. The presence of amyloidosis in the HFpEF-amyloid group was confirmed by cardiac biopsy, while cardiac magnetic resonance imaging ruled out its presence in the HFpEF group. The study included 34 patients with HFpEF-amyloid and 33 patients with HFpEF. Conventional echocardiographic parameters were compared between all subjects among the groups, while deformational and rotational parameters were compared between 10 subjects in each group, as these had adequate imaging quality to measure the parameters.Both groups had similar left ventricular ejection fraction. Subjects in the HFpEF-amyloid group had more grade III diastolic dysfunction, a shorter deceleration time, and lower tissue Doppler e' wave velocities. Patients with HFpEF-amyloid had significantly more impaired left ventricular longitudinal and basal strains and higher relative apical sparing ratios. Conventional echocardiographic parameters with the highest diagnostic accuracy for HFpEF-amyloid were an interventricular septum thickness ≥1.3 cm, a Doppler average e' ≤6.5 cm/sec, a septal e' <5.3 cm, and a myocardial contraction fraction ≤24, each with an AUC >0.8. For deformational parameters, a relative apical sparing strain ratio of ≥1.5 and a basal longitudinal strain ≥-12% showed the highest accuracy to diagnose HFpEF-amyloid with AUC of 0.98 and 0.96, respectively (Table).ConclusionIn patients with HFpEF, specific conventional and deformational echocardiographic parameters could reveal patterns for earlier identification of cardiac amyloidosis. Our goal was to identify conventional, deformational, and rotational echocardiographic parameters that could differentiate heart failure patients with preserved ejection fraction secondary to amyloidosis (HFpEF-amyloid) vs. heart failure patients with preserved ejection fraction without amyloidosis (HFpEF).

BackgroundThere is increasing recognition that female patients supported by continuous flow left ventricular assist devices (CF-LVADs) have worse outcome in terms of overall survival and adverse events. However, reports on sex differences in risk of pump thrombosis have been inconclusive.ObjectiveOur aim was to evaluate the association between sex and the risk of pump thrombosis.MethodsWe included patients receiving a CF-LVAD at our institution from 2007 to 2017. The primary endpoint was time to first pump thrombosis during 3 years of follow up. The Kaplan-Meier method was used to analyze survival free of pump thrombosis based on sex and Cox regression was used to determine the predictors of pump thrombosis.ResultsOur cohort included 301 patients (median age 59), of which 49 (16.3%) were female. During a median follow up time of 846 (interquartile range 313-1096) days, 31 (10.3%) patients developed pump thrombosis. Survival free of pump thrombosis was lower in female patients (figure 1). After adjusting for covariates (including age, race, body mass index, heart failure etiology, LVAD types, LVAD designations and medical comorbidities), the risk of pump thrombosis was higher for female patients than male patients (hazard ratio 2.64, 95% confidence interval 1.22-5.69, p= 0.01).ConclusionThe risk of pump thrombosis following LVAD varies based on sex, with female patients at higher risk. Further research is warranted to fully understand these differences, and whether device management strategies should be tailored based on sex. There is increasing recognition that female patients supported by continuous flow left ventricular assist devices (CF-LVADs) have worse outcome in terms of overall survival and adverse events. However, reports on sex differences in risk of pump thrombosis have been inconclusive. Our aim was to evaluate the association between sex and the risk of pump thrombosis. We included patients receiving a CF-LVAD at our institution from 2007 to 2017. The primary endpoint was time to first pump thrombosis during 3 years of follow up. The Kaplan-Meier method was used to analyze survival free of pump thrombosis based on sex and Cox regression was used to determine the predictors of pump thrombosis. Our cohort included 301 patients (median age 59), of which 49 (16.3%) were female. During a median follow up time of 846 (interquartile range 313-1096) days, 31 (10.3%) patients developed pump thrombosis. Survival free of pump thrombosis was lower in female patients (figure 1). After adjusting for covariates (including age, race, body mass index, heart failure etiology, LVAD types, LVAD designations and medical comorbidities), the risk of pump thrombosis was higher for female patients than male patients (hazard ratio 2.64, 95% confidence interval 1.22-5.69, p= 0.01). The risk of pump thrombosis following LVAD varies based on sex, with female patients at higher risk. Further research is warranted to fully understand these differences, and whether device management strategies should be tailored based on sex.

IntroductionWe aim to evaluate trends in patient characteristics, causes of hospitalization, procedure utilization, and outcomes in hypertrophic cardiomyopathy (HCM) patients.MethodsData from the Nationwide Inpatient Sample database (NIS) were analyzed to identify all patients who had secondary diagnosis of HCM from 2007-2014.ResultsWe identified 139,342 HCM admissions from 2007 to 2014 (mean age 66±16 years, 62% female and 75% Caucasian). There was no significant difference in nationwide trends in regard to the number of admissions. The most common reason for hospitalizations were: acute heart failure (47%), atrial fibrillation (16%), cerebrovascular accident (2%), syncope (1.5%) ventricular tachycardia (1%), and ventricular fibrillation or sudden cardiac death (VF/SCD) (0.3%) (Table 1). In regard to interventions, 659 (0.47%) patients underwent alcohol septal ablation, 4790 (3.44%) underwent septal myomectomy, 659 (0.47%) underwent ablation for atrial fibrillation, 99 (0.07%) underwent ventricular tachycardia ablation, 4931 (3.54%) underwent implantable cardiac defibrillator (ICD) implantation, and 3823 (2.74%) underwent mitral valve replacement (MVR) (Table-2). Overall in-hospital mortality was 3%. There was a significant trend towards lower all-cause mortality from 2007 to 2014 (3.43% Vs 2.74% respectively; P trend <0.05). VF/SCA has the highest mortality (11%) followed by CVA (9%). Median overall length of stay (LOS) was 4 [2.0, 7.0] days; VF/SCA admissions had the longest LOS (5.8 days) followed by CVA (5.0 [3.0, 8.0] days). Mortality was 7% in patients undergoing MVR, followed by 2% in patients undergoing septal myomectomy. During the study period, 68 (0.5%) HCM patients received a left-ventricular assist device (LVAD) (mean age 48±13 and 15% female) and 172 (0.12%) patients underwent heart transplant (HT) (mean age 44±14 and 40% were female). The co-morbidity burden of the patients undergoing HT was lower than those undergoing LVAD implantation. No significant difference was found in the mortality and LOS between HCM patients undergoing LVAD implantation and HT.ConclusionAHF is the most common reason for admission among HCM patients. While there is a trend towards lower mortality in recent years, HCM patients admitted for VF/SCD and CVA have the highest mortality. Despite female patients with HCM being more likely to be hospitalized, they are less likely to undergo interventions.