BACKGROUND: While tricuspid annular plane systolic excursion (TAPSE) captures the predominant longitudinal motion of the right ventricle (RV), it does not account for ventricular morphology and radial motion changes in various forms of pulmonary hypertension. This study aims to account for both longitudinal and radial motions by dividing TAPSE by RV area and to assess its clinical significance. METHODS: We performed a retrospective analysis of 71 subjects with New York Heart Association class II to III dyspnea who underwent echocardiogram and invasive cardiopulmonary exercise testing (which defined 4 hemodynamic groups: control, isolated postcapillary pulmonary hypertension, combined postcapillary pulmonary hypertension, and pulmonary arterial hypertension). On the echocardiogram, TAPSE was divided by RV area in diastole (TAPSE/RVA-D) and systole (TAPSE/RVA-S). Analyses included correlations (Pearson and linear regression), receiver operating characteristic, and survival curves. RESULTS: On linear regression analysis, TAPSE/RVA metrics (versus TAPSE) had a stronger correlation with pulmonary artery compliance (r=0.48–0.54 versus 0.38) and peak VO 2 percentage predicted (0.23–0.30 versus 0.18). Based on the receiver operating characteristic analysis, pulmonary artery compliance ≥3 mL/mm Hg was identified by TAPSE/RVA-D with an under the curve (AUC) of 0.79 (optimal cutoff ≥1.1) and by TAPSE/RVA-S with an AUC of 0.83 (optimal cutoff ≥1.5), but by TAPSE with only an AUC of 0.67. Similarly, to identify peak VO 2 <50% predicted, AUC of 0.66 for TAPSE/RVA-D and AUC of 0.65 for TAPSE/RVA-S. Death or cardiovascular hospitalization at 12 months was associated with TAPSE/RVA-D ≥1.1 (HR, 0.38 [95% CI, 0.11–0.56]) and TAPSE/RVA-S ≥1.5 (HR, 0.44 [95% CI, 0.16–0.78]), while TAPSE was not associated with adverse outcomes (HR, 0.99 [95% CI, 0.53–1.94]). Among 31 subjects with available cardiac magnetic resonance imaging, RV ejection fraction was better correlated with novel metrics (TAPSE/RVA-D r=0.378 and TAPSE/RVA-S r=0.328) than TAPSE (r=0.082). CONCLUSIONS: In a broad cohort with suspected pulmonary hypertension, TAPSE divided by RV area was superior to TAPSE alone in correlations with pulmonary compliance and exercise capacity. As a prognostic marker of right heart function, TAPSE/RVA-D <1.1 and TAPSE/RVA-S <1.5 predicted adverse cardiovascular outcomes.

BACKGROUND:Transesophageal echocardiography (TEE) is the gold standard for the detection of valvular vegetations (VV). Differentiating small VV from degenerative changes is challenging and prone to inter-observer variability. We evaluated inter-observer agreement regarding aortic (AV) and mitral valve (MV) findings on TEEs ordered for suspected infective endocarditis (IE).METHODS:A total of 349 consecutive TEEs were evaluated. Studies were classified as "definite, possible, or no" IE with valve masses classified further by morphology. Nine faculty echocardiographers scored randomly selected TEEs of the AV (N = 38) and MV (N = 35). Inter-reader variability was calculated using the Fleiss/Scott Kappa (Kf).RESULTS:Positive blood cultures were present in 81% and 45% had definite IE by the modified Duke criteria. There was moderate reader agreement regarding the presence of a valvular mass for both the AV (Kf = .41, 95% CI [.30-.53]) and MV (Kf = .49, 95% CI [.34-.65]). For diagnosis of IE, there was fair agreement for the AV (Kf = .29, 95% CI [.18-.42]) and moderate agreement for the MV (Kf = .53, 95% CI [.36-.70]). Masses described as large, multi-lobulated, or pedunculated were more frequently categorized as clinical IE, (p < .006, both valves), however those with filamentous lesions were not (p < .001, both valves).CONCLUSIONS:In a large academic center, the inter-observer agreement for the presence of a left sided valvular mass was moderate and agreement regarding the final diagnosis of IE was fair to moderate, with better agreement among readers evaluating the MV. Lesion morphology is associated with the clinical diagnosis of IE.

Structural Heart Intervention (SHI) is a rapidly evolving field that requires a multidisciplinary team of experts to achieve procedural success. The echocardiographer is a key member of this team, applying advanced transesophageal echocardiography (TEE) imaging to aid in patient evaluation and device selection. The echocardiographer provides real-time guidance of device placement during an SHI procedure, evaluating the immediate outcome of the procedure. The echocardiographer also identifies any procedural complication and assists in guiding its resolution. Such TEE guidance is critical for complex atrial septal defect closure, left atrial appendage occlusion, transcatheter repair of paravalvular regurgitation, transcatheter edge to edge mitral valve repair (TEER) and transcatheter mitral valve replacement, transcatheter tricuspid valve repair, percutaneous closure of ventricular septal defects, and — in some cases — transcatheter aortic valve replacement (TAVR). The specific work of the echocardiographer during an SHI procedure, reflecting procedural time and intensity, is represented by Current Procedural Terminology (CPT) code 93355. It is important to recall the chronology associated with the development of CPT 93355. Prior to its development, only diagnostic and monitoring TEE CPT codes (CPT 93312; CPT 93315; CPT 93318) were available. These codes however were inadequate for capturing the procedural time, intensity, and expertise typically associated with guiding SHI procedures. In recognition, the American Society of Echocardiography (ASE), the American College of Cardiology (ACC), and the Society for Cardiovascular Angiography & Interventions (SCAI) coordinated advocacy efforts to remedy this situation. The original multi-societal request to the CPT Editorial Panel was to develop two code levels for interventional TEE: 933X1 for shorter interventions (e.g., atrial septal defect closure and patent foramen ovale closure) and 933X2 for longer interventions (e.g., TAVR, TEER, and repair of paravalvular regurgitation). This two-tiered coding approach was proposed based on anticipated procedural time and intensity, but this construct was not accepted by the American Medical Association (AMA) CPT Editorial Panel. After a two-year process of submission, review, and revision, a single TEE guidance code for SHI procedure was approved by the AMA CPT, valued by the AMA Specialty Society Relative Value Scale Update Committee (RUC), and ultimately reimbursed by the Centers for Medicare and Medicaid Services (CMS). This code — CPT 93355 — is used to report TEE guidance during an SHI procedure, as well as TEE evaluation of the surrounding cardiac structures. It includes probe insertion, navigation, image acquisition, and physician interpretation and reporting. When performed, contrast administration, spectral Doppler, color flow Doppler, and 3D imaging are also included in CPT 93355. This code became effective on January 1, 2015. The full descriptor is as follows:93355 - Echocardiography, transesophageal (TEE) for guidance of a transcatheter intracardiac or great vessel(s) structural intervention(s) (eg,TAVR, transcatheter pulmonary valve replacement, mitral valve repair, paravalvular regurgitation repair, left atrial appendage occlusion/closure, ventricular septal defect closure) (peri-and intraprocedural), real-time image acquisition and documentation, guidance with quantitative measurements, probe manipulation, interpretation, and report, including diagnostic transesophageal echocardiography and, when performed, administration of ultrasound contrast, Doppler, color flow, and 3D.1AMA CPT Professional Edition – 2021.https://www.ama-assn.orgGoogle Scholar The descriptor for CPT 93355 accounts for the pre-procedural, intra-procedural (including real-time decision-making), and post-procedural work associated with the TEE guidance of “transcatheter intracardiac or great vessel(s) structural interventions.” The physician work relative value units (wRVU) assigned to CPT 93355 is 4.66, as compared to the physician wRVU of 2.30 associated with CPT 93312, which describes a standard diagnostic TEE. CPT code 93355 anticipates 120 minutes of physician intra-service work and total physician time (pre-; intra-; post-procedural work) of 160 minutes. It is important to note that there is a National Correct Coding (NCCI) edit in place which does not permit the reporting of CPT 93355 with overlapping anesthesia services when performed by the same provider. CMS indicates that the delivery of the diagnostic and interventional periods of the 93355 TEE service are not to be performed simultaneously with the anesthesia service. This edit was issued in 2016, and in 2021 CMS reiterated the edit in the National Coverage Determination (NCD) for Transcatheter Edge-to-Edge-Repair (TEER). While the physician wRVU for CPT 93355 is 4.66, the physician wRVU for CPT 33418 (Transcatheter mitral valve repair) designated for the interventional physician deploying the device is 32.25, nearly seven-fold the value assigned to the SHI TEE imager. It is important however to recognize that CPT 33418 reflects not only the physician work associated with the procedure but also additional work associated with patient care, such as hospital discharge services and outpatient follow-up visits, performed during a 90-day global period. The intra-service time for CPT 33418 is 180 minutes, yet the total physician time is 561 minutes. In contrast, CPT 93355 reflects only the clinical work associated with providing imaging guidance during the interventional SHI procedure itself. Unlike CPT 33218, CPT 93355 focuses solely on the SHI procedure itself and does not account for care provided during a 90-day global period. It is also important to recognize that the physician time associated with CPT 93355 is intended to account for the typical time associated with the entire family of SHI procedures. While certainly there are SHI procedures of considerably longer duration than the 120 minutes/160 minutes respectively assigned for intra-service/total physician time, CPT methodology is predicated on procedural averages. (Once again, a two-tiered coding approach was originally proposed but was not accepted by the AMA CPT Panel.) For those SHI procedures of unusual duration or clinical complexity, a modifier 22 code may be applied. The modifier 22 code (Increased Procedural Services) may be appended to CPT code 93355 when the procedure performed has exceeded the normal range of complexity. Modifier 22 is used for increased procedural services and signifies that a physician has gone above and beyond the typical time and/or intensity of a particular procedure. When used appropriately, modifier 22 reimburses the physician for unforeseen difficulties or additional time spent that are not usually anticipated for the procedure. However, as coding staff will know, securing appropriate reimbursement takes more than simply attaching a modifier to a service code if a physician is to be compensated accordingly. When using modifier 22, the claim must be accompanied by documentation and a cover letter explaining the unusual circumstances. Documentation should include, but not be limited to, descriptive statements identifying the unusual circumstances, operative reports (stating the usual time for performing the procedure and the prolonged time due to complication, if appropriate), pathology reports, progress notes, and office notes. Language indicating unusual circumstances would include statements as to procedural difficulty, increased risk, extensive hemorrhage, or unexpected clinical findings. Note that a slight extension of the procedure (a procedure extended by < 30 minutes) or the performance of a routine part of a procedure do not validate the use of modifier 22. Please also note that this modifier should not be appended to evaluation & management (E&M) services. As SHI procedures have increased in sophistication, there has been a growing concern within the SHI community that the wRVU valuation of CPT 93355 may no longer adequately capture the work of the echocardiographer during SHI for valvular heart disease procedures. With publication of the COAPT trial results, and subsequent approval by the U.S. FDA for TEER in patients with functional mitral regurgitation, the volume of complex and lengthy transcatheter procedures requiring TEE guidance has grown substantially. Several alternative models exist which may ensure adequate compensation for the interventional echocardiographer. The pace of innovation within SHI has far exceeded the pace of change within coding and reimbursement. Coding changes are complex and time consuming (several years, typically) and include initial drafting of a code change proposal, presentation at AMA CPT Panel, RUC presentation and valuation, and finally, a CMS reimbursement decision. Given these realities, it behooves institutions engaged in SHI programs to pursue other means aside from CPT/RVUs derived valuations to support the work of the SHI physician team. There are multiple potential reimbursement models to support the interventional echocardiographer. Hospitals have developed a number of innovative approaches to better support interventional echocardiographers, recognizing them for their time and expertise. The following are three examples from different institutions: Institutions are empowered to recognize any work performed by physicians that the institution considers to be in its commercial interest. By Federal statute, any economic transaction between participants involved in U.S. healthcare must meet two criteria. First, the transaction must be “commercially reasonable.” CMS defines this as an arrangement that “would make commercial sense if entered into by a reasonable entity…and reasonable physician…even if there were no potential business referrals between parties.”2Orme N.M. Rihal C.S. Gulati R. Holmes D.R. Lennon R.J. Lewis B.R. et al.Occupational health hazards of working in the interventional laboratory: A Multisite Case Control Study of Physicians and Allied Staff.J Am Coll Cardiolol. 2015; 65: 820-826https://doi.org/10.1016/j.jacc.2014.11.056Crossref PubMed Scopus (70) Google Scholar Second, such transactions must be consistent with Fair Market Value (FMV), which is “…consistent with general market value…the compensation that would be included in a service agreement as the result of bona fide bargaining between well-informed parties to the agreement who are not otherwise in a position to generate business for the other party…”.3Federal Register/Vol. 69, No. 59, pg. 16093.https://www.gpo.gov/fdsys/pkg/FR-2004-03-26/html/040668.htmGoogle Scholar As a general principle, physicians with bona fide employment or formalized personal service arrangements are eligible to receive remuneration from healthcare entities provided both criteria are met. This certainly includes the vast majority of physicians engaged in performance of interventional TEE. As a means to implement this, the institution may set a prespecified “wRVU floor” for a physician's time spent engaged in performing interventional echocardiographic services. In general, such “wRVU floors” are set in full-day or half-day increments. The physician performs the procedure and submits appropriate CPT codes, which are billed in standard fashion. At a later date, the institution will engage in a “look back” at the physician's aggregate wRVUs on the day of the procedure. Any difference between the billed wRVUs and the prespecified wRVU floor are reconciled by the awarding of proxy wRVUs. An alternative approach to awarding proxy wRVUs favored by some institutions involves assigning time-based RVUs to clinical services as a means to achieve internal equity amongst SHI physician team members. In this model, each proceduralist submits appropriate CPT codes for the work performed, and these are billed per routine. What distinguishes this model, however, is that the physician is not credited by the institution with the wRVUs associated with the CPT code but instead with internally-derived, time-based RVUs (TVUs). Such TVUs are established by the institution for commonly performed services — TVUs are not exclusively applied to SHI procedures — on an annual basis. The attractiveness of this approach is that it allows the institution to make internal decisions as to the appropriate amount of time to be associated with performing specific services. Given the rapid pace of change of technologies and the inherently slower pace to CPT valuation/revaluation, many organizations have found this to be an effective approach to achieving internal equity. It must be recognized, however, that assigning TVUs must be performed on a prospective basis. Determining specific TVU valuations requires strong collaboration amongst the various specialists and subspecialists within the organization. A third approach adopted by organizations is to engage in an “equal share” compensation model. While there are numerous examples in practice, one cardiology group reports use of an “equal pay” compensation model for over the past 50 years. In this model, all full-time “principal physicians” — analogous to a full business partner in the private practice setting — receive equal compensation regardless of cardiology subspecialty, wRVU production, or seniority. Although total practice wRVUs are tabulated for purposes of overall group practice fair market valuation determination, individual wRVUs are not circulated amongst physicians. The benefit of this compensation model is that it serves to unlink an individual physician's personal compensation from the personal pace of clinical activity. It also serves to remove individual financial reward from clinical decision-making, and it supports physician participation in critically important but less financially remunerative tasks such as teaching, program development, or providing TEE guidance of transcatheter procedures. Adoption of such a model requires a strong commitment on the part of all within the organization to value all individual contributions equally. A strong culture of mutual respect for each member's contributions is essential for this model to be successful. It is anticipated that SHI procedures will continue to advance in their application and sophistication. As has been the experience with TAVR, it is also anticipated that the time devoted to specific SHI procedures will invariably shorten as technologies further mature and physicians become more expert in their procedural command. Yet present experience also seems to be that just when mastery of one approach is achieved, another newer potential application emerges. How can a process as dynamic as SHI procedural advancement be appropriately described and valued by a payment system that by its very nature is so constrained and regimented?

Schwannomas are typically benign, indolent neoplasms. Primary pericardial schwannomas are extremely rare and arise from the cardiac plexus and vagus nerve innervating the heart. Few case reports have been documented to date. Pericardial schwannomas are difficult to diagnose at plain radiography or transthoracic echocardiography, often leading to further characterization with either CT or MRI. Biopsy is required for definitive diagnosis. A case of primary pericardial schwannoma of the posterior pericardium with concerns for compression of the left atrium and left ventricle is presented. © RSNA, 2021.

PURPOSE Several types of structural heart intervention (SHI) use information from multiple imaging modalities to complete an interventional task. For example, in Transcatheter Aortic Valve Replacement (TAVR), placement and deployment of a bioprosthetic aortic valve in the aorta is primarily guided by x-ray fluoroscopy (XRF), and echocardiography provides visualization of cardiac anatomy and blood flow. However, simultaneous interpretation of independent x-ray and echo displays remains a challenge for the interventionalist. The purpose of this work was to develop a novel echo/x-ray co-registration solution in which volumetric transthoracic echo (TTE) is transformed to the x-ray coordinate system by tracking the three-dimensional (3D) pose of a probe fiducial attachment from its appearance in two-dimensional (2D) x-ray images. METHODS A fiducial attachment for a commercial TTE probe consisting of rings of high-contrast ball bearings was designed and fabricated. The 3D pose (position and orientation) of the fiducial attachment is estimated from a 2D x-ray image using an algorithm in which a virtual point cloud model of the attachment is iteratively rotated, translated, and forward-projected onto the image until the average sum-of-squares of grayscale values at the projected points is minimized. Fiducial registration error (FRE) and target registration error (TRE) of this approach were evaluated in phantom studies using TAVR-relevant gantry orientations and four standard acoustic windows for the TTE probe. A patient study was conducted to assess the clinical suitability of the fiducial attachment prototype during TTE imaging of patients undergoing SHI. TTE image quality for the task of guiding a transcatheter procedure was evaluated in a reviewer study. RESULTS The 3D FRE ranged from 0.32 ± 0.03 mm (mean ± SD) to 1.31 ± 0.05 mm, depending on C-arm orientation and probe acoustic window. The 3D TRE ranged from 1.06 ± 0.03 mm to 2.42 ± 0.06 mm. Fiducial pose estimation was stable when > 75% of the fiducial markers were visible in the x-ray image. A panel of reviewers graded the presentation of heart valves in TTE images from 48 SHI patients. While valve presentation did not differ significantly between acoustic windows (p > 0.05), the mitral valve did achieve a significantly higher image quality compared to the aortic and tricuspid valves (p < 0.001). Overall, reviewers perceived sufficient image quality in 76.5% of images of the mitral valve, 54.9% of images of the aortic valve, and 48.6% of images of the tricuspid valve. CONCLUSIONS Fiducial-based tracking of a commercial TTE probe is compatible with clinical SHI workflows and yields 3D target registration error of less than 2.5 mm for a variety of x-ray gantry geometries and echo probe acoustic windows. Although TTE image quality with respect to target valve anatomy was sufficient for the majority of cases examined, pre-screening of patients for sufficient TTE quality would be helpful.

Introduction Atrial fibrillation (AF) is one etiology of WHO group II post-capillary pulmonary hypertension (PH). Higher left atrial pressure, estimated as pulmonary artery wedge pressure (PAWP) out of proportion to left ventricular end-diastolic pressure (LVEDP), has been reported in AF. However, the impact of atrial scarring associated with AF ablation (ABL) on these pressure differences remains unclear. Hypothesis Extensive AF ABL leads to scarring of the left atrial wall, decreasing atrial compliance, which leads to elevated left atrial pressure in the presence of a lower LVEDP creating a PAWP-LVEDP gradient. Methods We selected all patients who were diagnosed with PH (n=4,945) between 2009 and 2019 at the University of Wisconsin-Madison who underwent simultaneous right and left heart catheterization and had an EP procedure (n=27), after excluding patients with significant mitral valve disease and amyloid. We then divided them into 3 groups: group 1 (AF-ABL) n=5, group 2 (AF) n=16, group 3 (no AF) n=6. Results The PAWP-LVEDP gradient among three groups was (AF-ABL vs AF vs No AF): +6.8±3.42 vs -0.2±4.4 vs -1.8±4.0 mm Hg (Figure). Among the overall cohort, we further analyzed the patients with PAWP-LVEDP gradient >2 (discordant) vs ≤2 (concordant). PAWP-LVEDP gradient between the discordant group (n=12) vs the concordant group (n=15) was +5.0±2.7 vs -2.7±3.6*. Among the discordant group, 5 had AF ABL and 6 had AF. Among the concordant group, 5 had no AF, 10 had AF and no patients had AF ABL. The characteristics between discordant (DIS) vs concordant (CON) groups were: Age 68.2 ± 10 vs 67.0 ± 19.3, BMI 33.6 ± 4.55 vs 30.8 ± 11.2, diabetes 33% vs 47%, hypertension 75% vs 67%, OSA 91% (11/12) vs 40% (6/15)*, systolic pulmonary artery pressure (PAP) 55±19 vs 41±11*, mean PAP 37±12 vs 29±8*, PAWP 20±6 vs 18±7*, LVEDP 15±6 vs 20±7*. All patients who underwent ablation had persistent type AF and had extensive ablation beyond PVI (4 of 5 with PVI). Among the 16 patients with AF (without ABL - 6 in DIS, 10 in CON groups), 8 had paroxysmal (3 in DIS, 5 in CON) and 8 had persistent AF (3 in DIS, 5 in CON). While age, BMI, HTN and DM were similar among DIS vs CON groups, the incidence of OSA was higher. However, given the patients with elevated PAWP-LVEDP gradient have worse PH, we suspect they were more likely to be tested for OSA (referral bias). Conclusion AF ablation is associated with an increased PAWP-LVEDP gradient likely from atrial scarring and non-compliance of the left atrium. Patients with elevated PAWP-LVEDP gradient have worse pulmonary hypertension and are more likely to be diagnosed with OSA.

Sudden cardiac death in a young healthy athlete is a rare but catastrophic event. The American Heart Association preparticipation screening guidelines recommend a focused history and physical without routine imaging or electrocardiogram screening. We hypothesized that a focused echocardiogram can identify structural abnormalities that may lead to sudden cardiac death in athletes, which might otherwise go undetected by history and physical. We retrospectively reviewed the charts of all incoming collegiate athletes at a single university from 2005 to 2013, all of whom had undergone a focused, 5-minute echocardiogram along with a guideline-based preparticipation history and physical (PPS H&P). Abnormal findings prompted further testing or referral. We report the prevalence of abnormal findings and the relation between an abnormal PPS H&P and screening echocardiogram. A total of 2,898 athletes were screened and 159 (5%) had findings. Forty athletes underwent further testing and evaluation. Of these athletes, 3 had newly diagnosed abnormalities that warranted restriction of participation: 1 apical-variant hypertrophic cardiomyopathy, 1 large bidirectional atrial septal defect with right ventricular dysfunction, and 1 dilated ascending aorta. Two of these athletes had a normal PPS H&P. Conversely, of the 661 athletes with an abnormal PPS H&P, only 1 (0.15%) had an abnormal screening echocardiogram. In conclusion, although the overall number was low, the 5-minute screening echocardiogram detected athletes at risk for sudden cardiac death not discovered on PPS H&P.

This document is endorsed by the following American Society of Echocardiography International Alliance Partners: Argentine Federation of Cardiology, Argentine Society of Cardiology, ASEAN Society of Echocardiography, Australasian Sonographers Association, British Society of Echocardiography, Canadian Society of Echocardiography, Chinese Society of Echocardiography, Department of Cardiovascular Imaging of the Brazilian Society of Cardiology, Indian Academy of Echocardiography, Indian Association of Cardiovascular Thoracic Anaesthesiologists, Indonesian Society of Echocardiography, InterAmerican Association of Echocardiography, Iranian Society of Echocardiography, Israel Work Group on Echocardiography, Italian Association of Cardiothoracic Anaesthesiologists, Japanese Society of Echocardiography, Korean Society of Echocardiography, National Society of Echocardiography of Mexico, Philippine Society of Echocardiography, Saudi Arabian Society of Echocardiography, Thai Society of Echocardiography, Vietnamese Society of Echocardiography.

Editorials21 November 2017Acute Heart Failure in the Emergency Department: What Is the Prognosis?Peter S. Rahko, MDPeter S. Rahko, MDFrom University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M17-2389 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Heart failure (HF) is and will continue to be a major clinical problem in the United States, with an estimated prevalence of 6.5 million that is projected to increase to 8 million by 2030. Persons with HF account for about 1 million acute care hospitalizations, 2 million outpatient visits, and at least 500 000 emergency department (ED) evaluations annually (1). Patients with HF typically are older than 55 years and fragile and have multiple comorbid conditions, such as hypertension, coronary artery disease, atrial fibrillation, diabetes, and chronic renal insufficiency. Only about half have systolic dysfunction (ejection fraction <0.40), for which treatment ...References1. Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation. 2017;135:e146-e603. [PMID: 28122885] doi:10.1161/CIR.0000000000000485 CrossrefMedlineGoogle Scholar2. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, et al; American College of Cardiology Foundation. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62:e147-239. [PMID: 23747642] doi:10.1016/j.jacc.2013.05.019 CrossrefMedlineGoogle Scholar3. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, et al; Authors/Task Force Members. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37:2129-200. [PMID: 27206819] doi:10.1093/eurheartj/ehw128 CrossrefMedlineGoogle Scholar4. Forrester JS, Diamond G, Chatterjee K, Swan HJ. Medical therapy of acute myocardial infarction by application of hemodynamic subsets (second of two parts). N Engl J Med. 1976;295:1404-13. [PMID: 790194] CrossrefMedlineGoogle Scholar5. Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH, et al. Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. J Am Coll Cardiol. 2003;41:1797-804. [PMID: 12767667] CrossrefMedlineGoogle Scholar6. Stiell IG, Perry JJ, Clement CM, Brison RJ, Rowe BH, Aaron SD, et al. Prospective and explicit clinical validation of the Ottawa Heart Failure Risk Scale, with and without use of quantitative NT-proBNP. Acad Emerg Med. 2017;24:316-327. [PMID: 27976497] doi:10.1111/acem.13141 CrossrefMedlineGoogle Scholar7. Miró Ò, Rossello X, Gil V, Martín-Sánchez FJ, Llorens P, Herrero-Puente P, et al. Predicting 30-day mortality for patients with acute heart failure in the emergency department. A cohort study. Ann Intern Med. 2017;167:698-705. doi:10.7326/M16-2726 LinkGoogle Scholar8. Lee DS, Stitt A, Austin PC, Stukel TA, Schull MJ, Chong A, et al. Prediction of heart failure mortality in emergent care: a cohort study. Ann Intern Med. 2012;156:767-75, W-261, W-262. [PMID: 22665814]. doi:10.7326/0003-4819-156-11-201206050-00003 LinkGoogle Scholar9. Collins SP, Jenkins CA, Harrell FE, Liu D, Miller KF, Lindsell CJ, et al. Identification of emergency department patients with acute heart failure at low risk for 30-day adverse events: the STRATIFY decision tool. JACC Heart Fail. 2015;3:737-47. [PMID: 26449993] doi:10.1016/j.jchf.2015.05.007 CrossrefMedlineGoogle Scholar10. Stiell IG, Clement CM, Brison RJ, Rowe BH, Borgundvaag B, Aaron SD, et al. A risk scoring system to identify emergency department patients with heart failure at high risk for serious adverse events. Acad Emerg Med. 2013;20:17-26. [PMID: 23570474] doi:10.1111/acem.12056 CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: From University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.Disclosures: The author has disclosed no conflicts of interest. His form can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-2389.Corresponding Author: Peter S. Rahko, MD, Division of Cardiovascular Medicine, Mail Stop 3248, University of Wisconsin Hospital, 600 Highland Avenue, Madison, WI 53792-3248; e-mail, [email protected]wisc.edu.This article was published at Annals.org on 3 October 2017. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoPredicting 30-Day Mortality for Patients With Acute Heart Failure in the Emergency Department Òscar Miró , Xavier Rossello , Víctor Gil , Francisco Javier Martín-Sánchez , Pere Llorens , Pablo Herrero-Puente , Javier Jacob , Héctor Bueno , Stuart J. Pocock , and Metrics 21 November 2017Volume 167, Issue 10Page: 744-745KeywordsEmergency departmentHeart failureHospitalizationsLong-term careMortalityOutpatientsPopulation statisticsTreatment guidelinesTriageTroponin ePublished: 3 October 2017 Issue Published: 21 November 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

Background Bleeding and thromboembolic events (TE) are common complications following HeartMate II (HMII) implantation. The aim of the study was to review our experience related to bleeding and TE events in patients with a HMII and identify factors associated with increased risk of these events. Methods We retrospectively reviewed 70 consecutive patients who received a HMII between May 2006 and December 2011. The patients were followed for 12 months or until cardiac transplantation, device explantation or death. Major bleeding was defined by INTERMACS criteria with intracranial bleeding events added. Results There were 48 bleeding events in 28 (40%) patients with gastrointestinal bleeding (54.2%) being most common. Patients with bleeding events had significantly higher average INR (p=0.04) and more chronic kidney disease (p=0.03), although 43.8% of bleeding events occurred at an INR <2. Twelve TE events occurred in 9 patients (12.9%), with ischemic stroke the most common (75%). TE events were associated with young age (p=0.04) and non-diabetes status (p=0.03) and were not associated with average INR. There was no association of bleeding or thromboembolism with gender, BMI, HMII speed, pulsatility index, hypothyroidism, smoking history or INTERMACS profile at the time of HMII implantation. Conclusion Different factors are associated with bleeding and TE events. The appropriate target INR range for HMII patients should be chosen to balance the risk between bleeding and TE events based largely on patient factors.