BACKGROUND The prevalence of heart failure (HF) is rising and the only corrective treatment is cardiac transplantation. Advanced HF is associated with congestive hepatopathy and progressive functional and ultrastructural changes of the liver. We hypothesized that hepatic dysfunction is associated with impaired clinical outcome after heart transplantation. METHODS Data of 617 adult patients (75% males, mean age of 53±12 years, mean BMI of 25±4 and mean ejection fraction of 19±9%) undergoing orthotopic heart transplantation (OHT) were analyzed retrospectively. Deviation from institutional normal ranges was used to define abnormal liver function. Standard model for end Stage liver disease (MELD) scores were calculated and a modified MELD score with albumin replacing INR (modMELD) was created to eliminate the confounding effects of anticoagulation. RESULTS Before OHT, AST, ALT and total bilirubin were elevated in 20%, 18% and 29% of the population, respectively. Total protein and albumin were decreased in 25 and 52% of the population, respectively. By 2 months post-transplantation, percentages of individuals with pathological values decreased significantly except ALT, total protein and albumin, all of which took longer to normalize. Individuals with a higher pre-transplantation MELD or modMELD score had worse outcome 30 days post-transplant and reduced long-term survival over a 10-year follow-up. CONCLUSIONS In this large, single-center retrospective study, we demonstrate dynamics of liver dysfunction after cardiac transplantation and that elevated MELD scores indicating impaired liver function are associated with poor clinical outcome following OHT. Therefore, preoperative liver dysfunction has a significant impact on survival of patients after cardiac transplantation.

Objectives This study aimed to investigate the utility of serial tissue Doppler imaging (TDI) and speckle tracking echocardiography (STE) for monitoring right ventricular failure (RVF) after left ventricular assist device (LVAD) surgery. Background RVF post-LVAD is a devastating adverse event. Methods The authors prospectively studied 68 patients undergoing elective LVAD surgery. Echocardiograms were performed within 72 h before and 72 h after surgery. RVF was pre-specified as: 1) the need for salvage right ventricular assist device (RVAD); or 2) persistent need for inotrope and/or pulmonary vasodilator therapy 14 days after surgery. Patients were classified as Group RVF or Group Non-RVF. Results A total of 24 patients (35.3%) met criteria for RVF. Preoperative TDI-derived S’ was lower and RV E/E’ ratio was higher (3.7 ± 0.6 cm/s vs. 4.7 ± 0.9 cm/s, 12.0 ± 2.3 vs. 10.0 ± 2.5, both p < 0.001, respectively), and the absolute value of RV longitudinal strain (RV-strain) obtained from STE was lower (−12.6 ± 3.3% vs. −16.2 ± 4.3%, p < 0.001) in Group RVF vs. Group Non-RVF. Echo parameters within 72 h after surgery showed higher RV-E/E’, (13.9 ± 4.6 vs. 10.1 ± 3.0, p < 0.001) and lower RV-strain (−11.8 ± 3.5% vs. −16.7 ± 4.4%, p < 0.001) in Group RVF vs. Group Non-RVF. Preoperative S’ <4.4 cm/s, RV-E/E’>10 and RV-strain < −14% discriminated patients who developed RVF at day 14 with a predictive accuracy of 76.5%. When we included postoperative RV-E/E’ and RV-strain, the predictive accuracy increased to 80.9%, with a sensitivity of 66.7% and a specificity of 88.7%. Conclusions Serial echocardiograms using TDI and STE before and soon after LVAD surgery may aid in identifying need to initiate targeted RVF specific therapy in this population.

Objective Some have suggested the superiority of biatrial versus left atrial lesions. We sought to analyze our experience. Methods We retrospectively reviewed 305 consecutive patients from 2007 to 2011. Rhythm success was defined as freedom from atrial fibrillation (AF) or flutter determined by 12-lead electrocardiograms at 3-month intervals. Lesions sets were pulmonary vein isolation (PVI), left-extended (PVI + mitral valve annulus [MV] lesion ± left atrial appendage lesion [LAA]) or biatrial-extended (right atrial ablation + PVI + MV ± LAA). Results The success rates of PVI, left-extended, and biatrial-extended lesions were as follows: at 3 months, 56.7%, 74.7%, and 79.4% (P = .003); at 6 months, 56.9%, 72.9%, and 74.6% (P = .02); at 9 months, 54.6%, 72.5%, and 83.3% (P < .001); and at 12 months, 52.6%, 76.1%, and 80.0% (P < .001). Biatrial lesions had a higher rate of pacemaker placement than did left atrial lesions (16.5% vs 7.5%; P = .02). When we grouped patients by left lesion (PVI, PVI + MV, PVI + MV + LAA) irrespective of right atrial ablation, success was as follows: 3 months, 57.9%, 71.1%, and 87.8% (P < .01); 6 months, 58.1%, 71.6%, and 77.6% (P = .03); 9 months, 55.9%, 71.3%, and 89.6% (P < .01); and 12 months, 54.1%, 74.7%, and 83.7% (P < .01). Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set. The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy, but it does increase the rate of pacemaker placement for sinus dysfunction. Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV.

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Background Risk stratification of ambulatory heart failure (HF) patients has relied upon peak VO2 (pVO2) <14 mL/min/kg. We investigated whether additional clinical variables might further specify risk of death, ventricular assist device (VAD) implantation (INTERMACS<4) or heart transplantation (HTx; Status 1A or 1B) within one-year after HTx evaluation. We hypothesized that right ventricular stroke work index (RVSWI), pulmonary capillary wedge pressure (PCWP) and the Model for End-stage Liver Disease-Albumin score (MELD-A) would be additive prognostic predictors. Methods We retrospectively collected data on 151 ambulatory patients undergoing HTx evaluation. Primary outcomes were defined as HTx, LVAD or death within one-year following evaluation. Results Our cohort was 54.9±11.1 year-old, 79.1% male, 37.6% with ischemic etiology (LVEF 21±11% and pVO2 12.6±3.5ml/min/kg). Fifty outcomes (33.1%) occurred (27 HTx, 15 VAD, and 8 deaths). Univariate logistic regression showed significant association of RVSWI (mmHg-L/m2) (OR0.47, p=0.036), PCWP (mmHg) (OR2.65, p=0.007), and MELD-A (OR2.73, p=0.006) with one-year events. Stepwise regression showed independent correlation of RVSWI<5 (OR6.70; p<0.01), PCWP>20 (OR5.48; p<0.01), MELD-A>14 (OR3.72; p<0.01) and pVO2<14 (OR3.36; p=0.024) with one-year events. A scoring system was composed with MELD-A>14 and pVO2<14, 1 point each, and PCWP>20 and RVSWI<5, 2 points each. A cutoff at 4 demonstrated a 54% sensitivity and 88% specificity for one-year events. Conclusions Ambulatory HF patients have significant one-year event rates. Risk stratification based on exercise performance, left-sided congestion, right ventricular dysfunction and liver congestion allows prediction of one-year prognosis. This study endorses early and timely referral for VAD and/or transplant.