Journal of Cardiac Failure最新文献

Background: Heart transplantation from hepatitis C positive donors is on the rise, yet there exists divergence in approaches to managing recipients of these organs. Practices range from prophylactic treatment of recipients prior to transplantation to delayed treatment following the detection of viremia, with no established consensus on the optimal approach.

Methods: An online survey was conducted among the heart transplant centers in the United States of America and Canada from January 2023 to February 2024. The survey gathered comprehensive information from the institutions regarding direct antiviral (DAA) therapies used, timing and duration of DAA, frequency of viral load testing, adverse effects, virological response and immunosuppressive therapy modifications. The treatment pathways were categorized based on the timing of treatment initiation into prophylactic, preemptive, or reactive approaches. Analysis was restricted to US adult transplant programs that had an HCV transplant protocol and performed at least one HCV NAT positive transplant. The SRTR database was queried for total heart transplants using HCV NAT positive donors.

Results: Of 122 heart transplant programs, 35 (28.7%) institutions responded. 689 heart transplants (49.1%) using HCV NAT positive donors were captured across institutions. Among 30 US institutions performing adult heart transplantation with HCV NAT positive donor hearts, 5 (16.7%) used prophylactic, 9 (30%) preemptive, and 16 (53.3%) reactive treatment pathways. Most employed pan-genotype DAA therapies for a median of 12 weeks. Significant heterogeneity existed in treatment and monitoring protocols.

Conclusion: Practice patterns for management of HCV NAT positive donor hearts vary significantly. Establishing registries and Randomized Control Trials for these patients is crucial for guiding future practices.

Background: The interstitial fluid compartment is disproportionally expanded in heart failure (HF). Enhancing sweat rate remove fluids and sodium directly from the interstitial compartment.

Objectives: To study the feasibility and efficacy of direct interstitial decongestion in hospitalized HF patients.

Methods: We used a device designed to enhance fluid and salt expulsion via the eccrine sweat glands. Patients were treated for 1-6 days in the hospital. Following discharge, home therapy continued for 30-60 days (1-4 treatments/week). The primary efficacy endpoint for the in-hospital phase was a fluid loss of ≥500 mL per ≥4h per treatment. Secondary performance endpoints included changes in congestion score and NT-pro-BNP levels, evaluated for each phase separately.

Results: We studied 15 patients, 12 completing both the hospital and home phases. During the in-hospital and home phases, median weight change due to device therapy was 2.4 Kg [IQR 2.20-3.77], and the primary endpoint was met in 86% of treatment sessions. During the home treatment, median weight loss was 3.1 Kg [IQR 0.6 to 7.4 Kg]. Congestion score declined from 6 [IQR 6-7] to 1 [IQR 1-1.5] at the end of home therapy (P=0.002). Median NT-proBNP levels decreased from 7732 [IQR 4694-9746] to 4984 pg/mL [IQR 3559-8950](P=0.01) during the hospital phase and to 3596 ng/mL [IQR 1640-5742](P=0.02) at the end of home therapy.

Conclusion: Fluid removal via the skin is useful in enhancing decongestion in hospitalized ADHF patients. Following hospital discharge, device therapy was associated with additional improvement in decongestion.

Background: The HEART-FID trial is the largest trial to test intravenous iron (ferric carboxymaltose [FCM]) versus placebo in patients with heart failure and iron deficiency. The results showed a modest but non-statistically significant reduction in important clinical outcomes, including all-cause mortality.

Objectives: We sought to understand the factors associated with all-cause mortality.

Methods: Data on patients enrolled in HEART-FID were used to determine factors associated with all-cause mortality via multivariable models. The models included key clinical characteristics, including treatment interactions identified in the primary analysis (age by sex and country of enrollment). All-cause mortality at 12 months and over the full duration of follow-up (median 23.1 months) was evaluated using Cox proportional hazard regression.

Results: A total of 3065 patients had 737 all-cause mortality events over the duration of the trial, with 289 events occurring in the first 12 months. Fewer patients randomized to FCM died by 12 months compared with the placebo group (131 receiving FCM vs. 158 receiving placebo; hazard ratio 0.82 [95% confidence interval: 0.65-1.04]). Patients who died were more likely to be older with diabetes, atrial fibrillation, lower ejection fraction and estimated glomerular filtration rate, and a higher N-terminal pro b-type natriuretic peptide (NT-proBNP) level. The 3 multivariable factors most strongly associated with all-cause mortality at 12 months were NT-proBNP level, country of enrollment, and 6-minute walk test distance. Similar results were seen for predicting all-cause mortality over the entire follow-up; the addition of an age × sex × FCM interaction yielded statistically significant results, with greater association of benefit from FCM found for older women than for other patient subgroups.

Conclusion: FCM, compared with placebo, was associated with a potentially clinically meaningful (but not statistically significant) reduction in all-cause mortality, with key predictors of mortality being natriuretic peptide level, country of enrollment, and 6-minute walk test distance.

Heart failure (HF) is associated with poor prognosis, especially when it progresses to cardiogenic shock (CS), where survival rates substantially decline. A key area of interest is the role of blood lactate as a biomarker in these conditions. Lactate is produced under normal physiological conditions but increases with impaired tissue perfusion, a hallmark of HF and CS. Elevated lactate levels result from increased production, reduced clearance, or both, and are often associated with worse outcomes. Traditionally considered a byproduct of anaerobic metabolism, lactate is now recognized as an important energy substrate, particularly in myocardial tissue during periods of metabolic stress. Recent studies suggest that dynamic lactate monitoring, including lactate clearance (LC), may provide critical insights into patient prognosis and response to therapy. Serial measurements of lactate have been shown to predict survival in critically ill patients, including those with HF and CS. In CS, elevated lactate levels correlate with increased mortality risk, and LC is emerging as an important parameter in treatment protocols. Despite growing evidence of lactate's clinical relevance, research is needed to establish standardized thresholds and optimal monitoring timelines. Understanding the complexities of lactate metabolism and its role in HF and CS could lead to improved risk stratification and more personalized treatment approaches.

The author describes her personal experience with a cardiac diagnosis to demonstrate how wellness disparities are often rooted in historical constructions of "ideal" physical presentation that are both racialized and gendered. Her experiential analysis contends that failure to contextualize patients and divorce them from these historically problematic constructions is used to justify their profound disability and death.

Background: The benefit of implantable cardioverter-defibrillators (ICD) and cardiovascular resynchronization therapy (CRT-D) in patients supported with a HeartMate 3 left ventricular assist device (LVAD) remains uncertain.

Methods: An analysis of the MOMENTUM 3 randomized clinical trial and the first 1000 patients in the Continued Access Protocol trial. Patients were divided into three groups based on the presence of ICD and/or CRT-D: No device (n=153, 11%), ICD only (n=699, 50.4%), CRT-D (n=535, 38.6%). We assessed the association of ICD or CRT-D with overall mortality, ventricular arrhythmias (VA), rehospitalization rates, quality of life and six-minute walk test distance at 2-years of follow-up.

Results: Patients with ICD or CRT-D had similar survival to those without (HR 1.3, 95% CI 0.8-2.1, p=0.36) with no differences in rehospitalizations, quality-of-life or six-minute walk test distance. VA occurred more frequently in patients with ICD or CRT-D (HR 2.4, 95% CI 1.3-4.3, p=0.006). Compared to ICD alone, patients with CRT-D demonstrated similar survival (HR 1.1, 95% CI 0.9-1.5, p=0.36), however, had increased rates of VA (HR 1.3, 95% CI 1.0-1.7, p=0.03). There were no differences in rate of rehospitalization between those with ICD or CRT-D and those without (p=0.19) or between those with ICD and those with CRT-D (p=0.32). A propensity-matched sensitivity analysis confirmed these findings.

Conclusions: In this post-hoc analysis of the MOMENTUM 3 trial, the presence of ICD or CRT-D at the time of HM3 LVAD implantation was associated with an increased incidence of VA but was not associated with survival, quality of life or functional capacity.

Trial registration: Momentum 3 portfolio, NCT02224755 (Pivotal) and NCT02892955 (CAP).

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