Introduction Comorbidities are important considerations when determining whether a patient receives a left ventricular assist device (LVAD) as a bridge to a heart transplant (BTT) or destination therapy (DT). Patients with more severe or numerous comorbidities may be allocated DT-LVAD due to the risk of clinical deterioration while on the waitlist. Few studies have examined the relationship between pre-implant comorbidity presence and post-implant outcomes. Hypothesis We hypothesized that 1) comorbidities were considered contraindications to transplant in DT patients more than BTT patients and 2) comorbidities were more predictive of adverse events after implantation in DT patients more often than BTT patients. Methods We selected reported comorbidities in the Intermacs registry from 2007-2017 that were most likely to be physiologically related to adverse clinical events, stratified by device strategy. We performed chi-square tests to compare whether the presence of each comorbidity and classification of comorbidities as transplant contraindications differed by device strategy. We used cox proportional hazard models to determine whether the presence of each comorbidity was predictive of adverse events after implant. Results Among 12,848 BTT and 11,354 DT patients, there were only three comorbidities that did not have significantly higher rates of presentation in DT patients compared to BTT patients. BTT and DT patients were equally as likely to have heparin induced thrombocytopenia as a comorbidity, but DT patients were more likely to have this considered a contraindication to transplant. DT patients and BTT patients had similar rates of pulmonary embolism as a contraindication, though the event occurrence was low (66 cases total). Patients with DT and BTT were equally likely to have GI bleed as a comorbidity and transplant contraindication. There was variability for which comorbidities predicted clinical outcomes between BTT and DT populations (Table). The most consistent predictors of adverse events in both BTT and DT patients were chronic infection as a predictor of post-implant infection, history of stroke in predicting major stroke, chronic renal disease in predicting renal dysfunction, and pulmonary disease in predicting respiratory failure. Conclusion Certain comorbidities predict adverse post-implant events with greater accuracy than others, regardless of device strategy. This suggests that the presence of these comorbidities may not play as strong of a role in device strategy selection. There is a need for structured decision making when it comes to allocation of LVAD as DT or BTT based on predilection for certain post-implant adverse events.

Introduction Patients with advanced heart failure will often have progression of disease despite optimal medical therapy, eventually requiring mechanical circulatory support (MCS) as either a bridge to cardiac transplantation or destination therapy. To monitor MCS outcomes, the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) registry was created to monitor patients who receive continuous flow LVADs (left ventricular assist devices). We aim to assess the impact of pre-implantation guideline-directed medical therapy (GDMT) on MCS outcomes. Methods A retrospective observational cohort from the INTERMACS registry of 21180 patients with continuous flow LVADs from 2007 to 2017 were included in this analysis. The impact of preimplantation angiotensin receptor blockers (ARB), angiotensin-converting enzyme inhibitors (ACE-i), beta-blockers (BB), and mineralocorticoid receptor antagonists (MRA) were evaluated on all-cause mortality, neurological dysfunction, renal disease, and rehospitalization. Cox proportional hazard models were used to evaluate the association between pre-implant GDMT and post-implant outcomes. Multivariate analysis was adjusted for age, gender, ethnicity/race, blood type, cardiomyopathy etiology, smoking status, BSA, cardiac index, and eGFR. Results Among 21180 LVAD recipients, all-cause mortality was reduced by ARB patients (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.79-0.94) and ACE-i patients (HR 0.93, 95% CI 0.88-0.99). Renal disease had a reduction with ARB (HR 0.77, 95% CI 0.68-0.88) and ACE-i use (HR 0.91, 95% CI 0.83-0.99). No GDMT therapies showed an association with neurological dysfunction or rehospitalization. Subgroup analysis showed Black race and male sex were associated with decreased mortality. Asian race was associated with a decreased rate of rehospitalization. Hispanic ethnicity and high BSA were associated with increased risk of renal disease. Conclusion This study confirms the importance of pre-implantation GDMT if able to be tolerated. Our data suggests that ARBs and ACE-I should be prioritized for reduction in mortality and renal disease. More data regarding the impact of new GDMT agents and fully optimized pre-implantation GDMT regimens on post-implantation outcomes is needed.

Coronary artery anomalies encompass a spectrum of congenital abnormalities affecting the origin, course, or termination of the major epicardial coronary arteries. Despite their rarity, coronary artery anomalies represent a significant burden on cardiovascular health due to their potential to disrupt myocardial blood flow and precipitate adverse cardiac events. While historically diagnosed postmortem, the widespread availability of imaging modalities has led to an increased recognition of coronary artery anomalies, particularly in adults. This review synthesizes current knowledge on the classification, mechanisms, and clinical implications of coronary anomalies, focusing on prevalent variants with significant clinical impact. We discuss strategies for medical and surgical management, as well as contemporary screening recommendations, acknowledging the evolving understanding of these anomalies. Given the breadth of possible variants and the limited data on some presentations, this review provides a framework to aid clinicians in the recognition and management of coronary anomalies, with a particular emphasis on their stratification by anatomical location. By consolidating existing knowledge and highlighting areas of uncertainty, this review aims to enhance clinical decision-making and improve outcomes for individuals with coronary anomalies.

Takotsubo cardiomyopathy (TCM) is a transient and reversible cardiomyopathy which exhibits regional wall motion abnormalities in the absence of obstructive coronary artery disease. While TCM is a rare condition (incidence <1%), its diagnosis has increased since its initial description in 1990. While many cases may follow an acute physical or emotional stressor, pathophysiology is likely multifactorial including factors such as catecholamine surges and microvascular dysfunction. On initial presentation, TCM often mimics acute coronary syndrome but may be differentiated with coronary angiography. Additional laboratory testing and imaging including transthoracic echocardiography may help with diagnosis and identification of complications such as left ventricular (LV) outflow obstruction and LV thrombus. Treatment is supportive, although medications such as angiotensin-converting enzyme inhibitors and beta-blockers have shown some benefit in improving long-term outcomes. Acute complications may include arrhythmia, LV or systemic thrombus, and cardiogenic shock, but most patients do well and experience rapid recovery. TCM continues to be an active area of research as there is still much to be learned regarding its pathogenesis, diagnosis, and treatment. This review analyzes the latest research to provide insight into the presentation, pathophysiology, diagnosis, and management of TCM.

Functional coronary angiography (FCA) is a novel modality for assessing the physiology of coronary lesions, going beyond anatomical visualization by traditional coronary angiography. FCA incorporates indices like fractional flow reserve (FFR) and instantaneous wave-free ratio (IFR), which utilize pressure measurements across coronary stenoses to evaluate hemodynamic impacts and to guide revascularization strategies. In this review, we present traditional and evolving modalities and uses of FCA. We will also evaluate the existing evidence and discuss the applicability of FCA in various clinical scenarios. Finally, we provide insight into emerging evidence, current challenges, and future directions in FCA.