You are cordially invited to join the Ohio-ACC for a special legislative day in Columbus, on May 7th with a kick-off dinner on May 6th. This will be a day of visiting your Ohio representatives and senators to introduce them to cardiology issues facing you and your patients. Building relationships with your state lawmakers will help ensure that the Ohio General Assembly remains informed of issues facing clinicians and patients. There is no charge for the event, and appointments with your lawmakers will be made for you. Parking will be validated. Get complete details here.

Issues that we have advocated for in the past that have become law include: raising the age to purchase cigarettes, other tobacco products, and alternative nicotine products such as e-cigarettes and vaping products from 18 to 21; Lindsay's Law which informs and educates students and youth athletes participating in or desiring to participate in athletic activity, their parents, and their coaches about the nature and warning signs of sudden cardiac arrest; and vital telehealth legislation. Your participation makes a difference!

A limited number of Ohio-ACC Legislative Day travel stipends are available on a first-come, first-served basis, which includes overnight accommodations for May 6 and parking. Contact ohioacc@gmail.com for this opportunity.

A plenary session at the Cardiovascular Summit featured an update and overview of the College’s work in collaboration with AHA, HFSA, HRS, and SCAI to create a new Board of Cardiovascular Medicine. The application review process is underway with the American Board of Medical Specialties and more details on the ways members can support this effort should be available in the coming weeks and months. In the meantime, an updated FAQ has been posted to a revamped CVBoard.org (http://cvboard.org/) site. Additionally, the site includes a direct link to the joint society webinar describing the process and answering some of the biggest questions about the new Board as well as an overview video.

If Gwen Goldfarb, our chapter executive, or I can be of assistance to you, please let us know.

The Ohio-ACC FIT council continues the successful Fellow Grand Rounds Series which presents noon sessions throughout the year. Each session rotates between different Ohio fellowship programs. The goal of the grand rounds is to bring a better understanding of elements of career development. Take a look at the recent session on Navigating the Transition from FIT to Early Career.

March 20, What Employers Are Looking for in a Candidate for a Cardiology Job. Register here.

May 1, Considerations for Choosing a Job: Private Practice, Academic, or Industry. Register here.

1. Please complete the application.

2. Have your program director or an Ohio-ACC Board Member send a letter of support to ohioacc@gmail.com by April 15.

Please take a moment to subscribe to the Ohio-ACC CardiOhio Podcast. Simply copy and paste this URL into the podcast app of your choice, or click here to view in Apple podcasts. These 30-minute audio podcasts are designed to provide practical management tips for our providers. We really hope that you will find this information useful for your practice.

Drs. Heather Gornik and Ellen Sabik, both from University Hospitals of Cleveland

Drs. Ankit Bhatia and Gregory F. Egnaczyk, both from The Christ Hospital in Cincinnati

For patients with advanced heart failure refractory to medications, durable left ventricular assist devices (LVADs) can be implanted to increase survival and improve symptoms. Of the third generation LVADs, the centrifugal-flow HeartMate3 (HM3; Abbott Laboratories) is the predominant LVAD implanted and will be the focus of this brief review. The average 5-year survival for patients with a HM3 LVAD is almost 60%, a significant improvement from <20% on medical therapy alone, with 2-year survival similar to heart transplant patients.¹

LVAD implantation is associated with risks such as bleeding, pump thrombosis, stroke, and infection. Bleeding complications are multifactorial, in part due to sheer stress from the continuous flow LVAD which leads to acquired von Willebrand disease causing a disruption in blood vessel formation and the development of arteriovenous malformations.² These changes are frequently implicated in gastrointestinal bleeding (GIB) which has a reported incidence ranging from 25-30% in the first year following implantation.¹ An antithrombotic regimen of warfarin (target international normalized ratio (INR) 2-3) and aspirin 81-100 mg daily is recommended to reduce the risk of pump thrombosis and stroke.^3,4 The need for aspirin as part of the antithrombotic regimen for the HM3 LVAD has been controversial given the lower risk of pump thrombosis and stroke compared to other models. Small studies have evaluated stopping aspirin in patients with HM3 LVADs at high bleeding risk or following a GIB episode to decrease the risk of subsequent GIB.^5,6 The ARIES-HM3 trial investigators sought to determine the clinical role and impact of the use of aspirin in patients with advanced heart failure with a HM3.⁷

ARIES-HM3 was an international, randomized, double-blind, placebo-controlled trial in patients with newly implanted HM3 LVADs. Patients were randomized to aspirin or placebo in addition to warfarin with target INR 2-3. Key exclusion criteria included patients with a mandated indication for antiplatelet therapy or unable to take medications by mouth through post-op day 7. A total of 628 patients were randomized between July 2020 to September 2022. Baseline characteristics between groups were similar apart from a higher incidence of diabetes in the placebo group (45.3% vs 36.2%). Medication adherence was high and similar between groups, and the time in therapeutic range of warfarin was also similar (55.1% vs 58.9%). The primary outcome was survival free of nonsurgical major hemocompatibility-related adverse events at 12 months (excluding events within 14-days of implant) comprised of bleeding, stroke, pump thrombosis, and peripheral thromboembolism events. With a median follow up of approximately 14 months, the use of placebo was noninferior to aspirin for the primary outcome (68.1% vs 74.2%, p <0.001), primarily driven by a reduction in bleeding (22.5% vs 28.2%) with a separation of curves seen around 1 month. There were no differences in rates of ischemic or hemorrhagic stroke, pump thrombosis, or survival. Notably, there was a 47% reduction in days spent in the hospital due to nonsurgical bleeding and a 41% reduction in the cost of bleeding episodes in the placebo group. Ultimately, this study found that removing aspirin from antithrombotic regimens post HM3 implant was noninferior to standard therapy and resulted in a reduction of bleeding events without increasing the risk of thromboembolic events. The ARIES trial does not provide evidence for patients who were previously implanted with a HM3, nor evidence for patients with other LVAD models. Additionally, the majority of patients were enrolled from North America (85%), so caution should be used when applying to practices outside of North America.

For patients undergoing index HM3 LVAD implantation, data from ARIES-HM3 supports the off-label removal of aspirin from initial antithrombotic regimens to decrease the risk of bleeding post-implant and rates of hospitalization. With cost savings estimated around $13,500 per bleeding episode, the financial impact of the removal of aspirin is projected to be significant.⁷ Health systems with LVAD programs should have multidisciplinary discussions with key stakeholders to discuss the risk and benefit of removing aspirin from initial antithrombotic regimens pending FDA review of this data. Case by case discussions with shared decision making are recommended for patients previously implanted with HM3 LVAD who remain on aspirin.

1. Tedford RJ, Leacche M, Lorts A, et al. Durable mechanical circulatory support: JACC Scientific Statement. J Am Coll Cardiol 2023;82:1464-1481.

2. Proudfoot AG, Davidson SJ, Strueber M. Von Willebrand factor disruption and continuous-flow circulatory devices. J Heart Lung Transplant 2017;36:1155-1163.

3. HeartMate 3TM left ventricular assist system: instructions for use. Pleasanton, CA: United States & Canada Thoratec Corporation. 2017.

4. Mehra MR, Uriel N, Naka Y, et al.; MOMENTUM 3 Investigators. A fully magnetically levitated left ventricular assist device - final report. N Engl J Med 2019;380:1618-27.

5. Lim HS, Ranasinghe A, Chue C, Mascaro J. Two-year outcome of warfarin monotherapy in HeartMate 3 left ventricular assist device: a single-center experience. J Heart Lung Transplant. 2020;39(10):1149-1151.

6. Consolo, F., Raimondi Lucchetti, M., Tramontin, C., Lapenna, E. and Pappalardo, F. (2019), Do we need aspirin in HeartMate 3 patients?. Eur J Heart Fail, 21: 815-817.

7. Mehra MR, Netuka I, Uriel N, et al. Aspirin and hemocompatibility events with a left ventricular assist device in advanced heart failure. JAMA 2023;330(22):2171-2181.

Be on the lookout for the AMA’s Relative Value Scale Update Committee (RUC) Surveys on PCI and left atrial appendage (LAA) closure services. You could be randomly selected to complete the survey, in which case participants will be asked to estimate the typical time, intensity, and complexity of their work and the Relative Value Unit (RVU) for the procedure in comparison to a list of reference services with established RVUs. Feedback from these surveys are used to create AMA recommendations to the Centers for Medicare and Medicaid Services. This cycle, the PCI family of codes is being surveyed, following the recent addition of intravascular lithotripsy as well as the existing code for percutaneous transcatheter closure of the LAA.

You can learn more about the RUC process here and contact Matthew Minnella with any questions.

Congress is three weeks away from the next government funding deadline with the continuing resolution set to expire March 8. Discussions are underway about the next funding package, and we must ensure that lawmakers include short-term relief from Medicare cuts. Your ACC has been actively engaged on this issue – meeting with House and Senate leadership and attending events with members who sit on key committees. Help to amplify these efforts by sending a message to your lawmaker today. Take action.

Salaries of cardiovascular advanced practice providers (APPs) increased 13% between 2018 and 2022, based on the 2023 Cardiovascular APP Compensation and Utilization Report released by MedAxiom. The report also finds that the APP per physician ratio is steadily climbing year-over-year, with big increases in cardiac surgery. Access more findings from the report, along with reminders for 2024 code changes and the paused CMS’ Appropriate Use Criteria program in the latest issue of Cardiology magazine. Read the full issue.

The ACC has officially launched the new CV ASC Registry Suite – the first unified registry for cardiac procedures performed in ambulatory surgery centers (ASCs) and office-based labs. With the expansion of ASCs performing select cardiac procedures on eligible patients throughout the U.S., the newest NCDR registry is the first of its kind to easily fit into the patient care workflow and provide these centers with data-driven insights for measuring care delivery and outcomes. The CV ASC Registry Suite leverages the existing NCDR CathPCI Registry and EP Device Implant Registry platforms and metrics to offer big-picture reviews, at-a-glance assessments and patient-level drilldowns on procedures such as diagnostic cardiac catheterization, PCI, and defibrillator and pacemaker implants. Learn more.

 Enhanced dashboards for NCDR’s hospital registries will continue to roll out beta version updates throughout this Spring as part of the College’s Digital Transformation and NCDR Optimization Plan investments. The new dashboards will provide more robust visualizations and a faster, more dynamic data customer experience to support hospitals, health systems and their clinical care teams in their commitment to optimize cardiovascular patient care and outcomes. Prepare for the new dashboards and learn more about the increased opportunities to provide actionable insights here. An “Introduction to NCDR’s New Dashboards” course is also available in the QII Learning Center, which is open to current NCDR and ACC Accreditation Services participants.

With more than 6 million Americans with heart failure, patient education is key in managing and living with this condition. To help patients better understand and manage heart failure, ACC’s CardioSmart team has developed a package of tools and resources including a new Action Plan for Heart Failure With Preserved Ejection Fraction (HFpEF). The package also includes infographics, decision aids, and updated tools teaching patients how to make the most of their follow-up visits, use checklists, daily trackers, and more. Download the tools for free.

CardioSmart is the ACC’s dedicated home for patient tools and resources, including infographics, shared decision-making aids, and more. Find information on specific clinical conditions, health lifestyle choices and more at CardioSmart.org.