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Pubblicazioni recenti - cardiac failure
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Cardiac Surgery in Patients with Dialysis-dependent End Stage Renal Failure: Single Centre Experience.
Rev Port Cir Cardiotorac Vasc;26(3):199-204.
Ranchordas Sara, Madeira Márcio, Pereira Tiago, Branco Patrícia, Gaspar Augusta, Marques Marta, Calquinha José, Abecacis Miguel, P Neves José,
Abstract
BACKGROUND:
Patients under dialysis have a high cardiovascular risk and they are at increased risk when submitted to cardiac surgery.
AIM OF THE STUDY:
to evaluate morbidity, early and late mortality, and predictive factors of mortality in patients under dialysis who underwent cardiac surgery.
METHODS:
A retrospective observational study was performed including all dialysis dependent patients who underwent cardiac surgery (coronary, valvular or combined procedures) in our institution between 2007 and 2014. A population of 95 consecutive patients was obtained (no exclusions). Perioperative variables and predictors of mortality were analysed and the endpoints were early and late mortality. Propensity score matching, with a control group of patients with creatinine clearance >90mL/min, was performed by logistic regression, with a 1:1 matching. Kaplan Meier curves were performed for late mortality.
RESULTS:
Early mortality was 9.4% (EuroSCORE II 4.1%). In univariate analysis, mean time of cardiopulmonary bypass (CPB) (p=0.016) and EuroSCORE II (p=0.02) were related with early mortality. In a multivariate analysis model, combined procedures (OR 138.09; CI95% 1.82-10498.4; p=0.03) and CCS (Canadian Cardiovascular Society) 3-4 (OR 70.951; CI 95% 1.32-3810.11; p=0.037) were predictors of mortality. In multivariable analysis, CPB time >152 min was a predictor of early mortality (p=0.001). After propensity score matching, 30 day, one year and late mortality were higher in the dialysis group.
CONCLUSIONS:
Early and late mortality were significantly higher in dialysis dependent patients. Predictive factors of mortality were CPB time and EuroSCORE II in univariable analysis, and CCS 3-4 and combined procedures in multivariable analysis.
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Treatment of Functional Mitral Regurgitation in Heart Failure.
Curr Cardiol Rep2019 Nov;21(11):139. doi: 10.1007/s11886-019-1221-x.
Fabris Enrico, De Luca Antonio, Vitrella Giancarlo, Stolfo Davide, Masè Marco, Korcova Renata, Merlo Marco, Rakar Serena, Van't Hof Arnoud W J, Kedhi Elvin, Perkan Andrea, Sinagra Gianfranco,
Abstract
PURPOSE OF REVIEW:
To analyze the current state of the art of functional mitral regurgitation (FMR) treatment.
RECENT FINDINGS:
The first-line treatment of severe FMR consists of guideline medical therapy (GMT) and resynchronization therapy when indicated; the impact of new medical therapies like sacubitril/valsartan needs further assessment. Valvular intervention may be considered in FMR symptomatic patients despite GMT, and can be performed surgically or percutaneously. MitraClip is a safe percutaneous procedure associated with symptoms improvement. Recently, the COAPT trial showed superior outcomes for MitraClip versus GMT contrasting the MITRA-FR trial which showed no benefit of MitraClip compared with GMT. These results should be interpreted as complementary rather than opposite. The COAPT trial provided a "proof of concept" that percutaneous treatment of severe FMR in patients without too advanced left ventricular disease translates into a prognostic benefit. Careful patient selection will play a critical role in defining the clinical niche for successful interventions.
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"The heart supporters": systematic review for ventricle assist devices in congenital heart surgery.
Heart Fail Rev2019 Nov;():. doi: 10.1007/s10741-019-09892-0.
Comentale Giuseppe, Giordano Raffaele, Pilato Emanuele, D'Amore Anna, Romano Roberta, Simeone Silvio, Browning Rosie, Palma Gaetano, Iannelli Gabriele,
Abstract
Ventricular assist device (VAD) implantation is a widely used procedure in children with cardiac failure refractory to medical therapy as a long-term bridge to recovery or transplant. This strategy has proved to be of an enormous advantage in the cure of these children. The aim of this review is to evaluate the current strategies used for clinical monitoring of paediatric patients with a VAD, focusing on the management of several aspects such as anticoagulant and antiplatelet therapy, haemorrhagic and thrombotic complications, as well as the effects that VADs have on the exposure, effectiveness and the safety of drugs. The sources used for this research are MEDLINE, PubMed and Cochrane Library. The use of key words such as "paediatric ventricular assist device", "clinical management", "anticoagulant therapy" and "infections" retrieved 146 papers. With the application of the inclusion criteria, 42 articles have been selected, but following further analysis, only 21 were eligible. The post-implant process is still complicated due to the lack of guidelines regarding clinical management and for the frequent occurrence of adverse events including bleeding, infection and thromboembolic episodes. From these findings, we can highlight the importance of establishing a suitable antithrombotic therapy, as well as ensuring that the prevention and treatment of infection are paramount during the management of these patients. The clinical management of VAD paediatric children is complex and challenging. At the moment, there are no guidelines regarding strategies to adopt, but from the analysed surveys, it has been possible to highlight a relative coherence between adopted therapies in different centres worldwide.
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Effects of a 9-Week Hybrid Comprehensive Telerehabilitation Program on Long-term Outcomes in Patients With Heart Failure: The Telerehabilitation in Heart Failure Patients (TELEREH-HF) Randomized Clinical Trial.
JAMA Cardiol2019 Nov;():. doi: 10.1001/jamacardio.2019.5006.
Piotrowicz Ewa, Pencina Michael J, Opolski Grzegorz, Zareba Wojciech, Banach Maciej, Kowalik Ilona, Orzechowski Piotr, Szalewska Dominika, Pluta Slawomir, Glówczynska Renata, Irzmanski Robert, Oreziak Artur, Kalarus Zbigniew, Lewicka Ewa, Cacko Andrzej, Mierzynska Anna, Piotrowicz Ryszard,
Abstract
Importance:
Guidelines recommend exercise training as a component of heart failure management. There are large disparities in access to rehabilitation, and introducing hybrid comprehensive telerehabilitation (HCTR) consisting of remote monitoring of training at patients' homes might be an appealing alternative.
Objective:
To assess whether potential improvements in quality-of-life outcomes after a 9-week HCTR intervention in patients with heart failure translate into improvement in clinical outcomes during extended 12 to 24 months of follow-up, compared with usual care.
Design, Setting, and Participants:
The Telerehabilitation in Heart Failure Patients (TELEREH-HF) trial is a multicenter, prospective, open-label, parallel-group randomized clinical trial that enrolled 850 patients with heart failure up to 6 months after a cardiovascular hospitalization with New York Heart Association levels I, II, or III and left ventricular ejection fraction of 40% or less. Patients from 5 centers in Poland were randomized 1:1 to HCTR plus usual care or usual care only and followed up for 14 to 26 months after randomization.
Interventions:
During the first 9 weeks, patients underwent either an HCTR program (1 week in hospital and 8 weeks at home) or usual care with observation. The HCTR intervention encompassed telecare, telerehabilitation, and remote monitoring of implantable devices. No intervention occurred in the remaining study period.
Main Outcomes and Measures:
The percentage of days alive and out of the hospital from randomization through the end of follow-up at 14 to 26 months.
Results:
A total of 850 patients were enrolled, with 425 randomized to the HCTR group (377 male patients [88.7%]; mean [SD] age, 62.6 [10.8] years) and 425 randomized to usual care (376 male patients [88.5%]; mean [SD] age, 62.2 [10.2] years). The HCTR intervention did not extend the percentage of days alive and out of the hospital. The mean (SD) days were 91.9 (19.3) days in the HCTR group vs 92.8 (18.3) days in the usual-care group, with the probability that HCTR extends days alive and out of the hospital equal to 0.49 (95% CI, 0.46-0.53; P?=?.74) vs usual care. During follow-up, 54 patients died in the HCTR arm and 52 in the usual-care arm, with mortality rates at 26 months of 12.5% vs 12.4%, respectively (hazard ratio, 1.03 [95% CI, 0.70-1.51]). There were also no differences in hospitalization rates (hazard ratio, 0.94 [95% CI, 0.79-1.13]). The HCTR intervention was effective at 9 weeks, significantly improving peak oxygen consumption (0.95 [95% CI, 0.65-1.26] mL/kg/min vs 0.00 [95% CI, -0.31 to 0.30] mL/kg/min; P?
Conclusions and Relevance:
In this trial, the positive effects of a 9-week program of HCTR in patients with heart failure did not lead to the increase in percentage of days alive and out of the hospital and did not reduce mortality and hospitalization over a follow-up period of 14 to 26 months.
Trial Registration:
ClinicalTrials.gov identifier: NCT02523560.
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Patient Perceptions and Familiarity With Medical Therapy for Heart Failure.
JAMA Cardiol2019 Nov;():. doi: 10.1001/jamacardio.2019.4987.
Samsky Marc D, Lin Li, Greene Stephen J, Lippmann Steven J, Peterson Pamela N, Heidenreich Paul A, Laskey Warren K, Yancy Clyde W, Greiner Melissa A, Hardy N Chantelle, Kavati Abhishek, Park Siyeon, Mentz Robert J, Fonarow Gregg C, O'Brien Emily C,
Abstract
Importance:
There are major gaps in use of guideline-directed medical therapy (GDMT) for patients with heart failure (HF). Patient-reported data outlining patient goals and preferences associated with GDMT are not available.
Objective:
To survey patients with chronic HF to better understand their experiences and perceptions of living with HF, including their familiarity and concerns with important GDMT therapies.
Design, Setting, and Participants:
Study participants were recruited from the GfK KnowledgePanel, a probability-sampled online panel representative of the US adult population. English-speaking adults who met the following criteria were eligible if they were (1) previously told by a physician that they had HF; (2) currently taking medications for HF; and (3) had no history of left ventricular assist device or cardiac transplant. Data were collected between October and November 2018. Analysis began in December 2018.
Main Outcomes and Measures:
The survey included 4 primary domains: (1) relative importance of disease-related goals, (2) challenges associated with living with HF, (3) decision-making process associated with HF medication use, and (4) awareness and concerns about available HF medications.
Results:
Of 30?707 KnowledgePanel members who received the initial survey, 15?091 (49.1%) completed the screening questions, 440 were eligible and began the survey, and 429 completed the survey. The median (interquartile range) age was 68 (60-75) years and most were white (320 [74.6%]), male (304 [70.9%]), and had at least a high school education (409 [95.3%]). Most survey responders reported familiarity with ?-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and diuretics. Overall, 107 (24.9%) reported familiarity with angiotensin receptor-neprilysin inhibitors or mineralocorticoid receptor antagonists. Overall, 136 patients (42.5%) reported have safety concerns regarding angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and 133 (38.5%) regarding ?-blockers, 35 (37.9%) regarding mineralocorticoid receptor antagonists, 38 (36.5%) regarding angiotensin receptor-neprilysin inhibitors, and 123 (37.2%) regarding diuretics. Between 27.7% (n = 26) and 38.5% (n = 136) reported concerns regarding the effectiveness of ?-blockers, angiotensin receptor-neprilysin inhibitors, mineralocorticoid receptor antagonists, or diuretics, while 41% (n = 132) were concerned with the effectiveness of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers.
Conclusions and Relevance:
In this survey study, many patients were not familiar with GDMT for HF, with familiarity lowest for angiotensin receptor-neprilysin inhibitors and mineralocorticoid receptor antagonists. Among patients not familiar with these therapies, significant proportions questioned their effectiveness and/or safety. Enhanced patient education and shared decision-making support may be effective strategies to improve the uptake of GDMT for HF in US clinical practice.
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Pre- Versus Post-Procedure Health Care Resource Utilization in Patients Undergoing Commercial Transcatheter Mitral Valve Repair.
JACC Cardiovasc Interv2019 Nov;():. doi: S1936-8798(19)32102-8.
Rymer Jennifer A, Li Zhuokai, Cox Morgan L, Bishawi Muath, Kosinski Andrzej S, Cohen David J, Wang Andrew, Kapadia Samir, Sorajja Paul, Carroll John D, Badhwar Vinay, Thourani Vinod, Glower Donald D, Vemulapalli Sreekanth,
Abstract
OBJECTIVES:
The aim of this study was to assess the real-world impact of transcatheter mitral valve repair (TMVr) on hospitalizations and Medicare costs pre- versus post-TMVr.
BACKGROUND:
TMVr is effective in degenerative mitral regurgitation (MR) and appropriately selected patients with functional MR with high surgical risk.
METHODS:
Patients undergoing TMVr in the Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry from 2013 to 2018 were linked to Medicare claims data. Rates of hospitalizations, hospitalized days, and Medicare costs were compared 1 year pre-TMVr to 1 year post-TMVr.
RESULTS:
Across 246 sites, 4,970 patients with a median age of 83 years (interquartile range: 77 to 87 years) were analyzed. The TMVr indication was degenerative MR in 77.5% and functional MR in 16.7%. From pre- to post-TMVr, heart failure (HF) hospitalization rates (479 vs. 370 hospitalizations/1,000 person-years; rate ratio [RR]: 0.77) and cardiovascular hospitalizations (838 vs. 632; RR: 0.75) decreased significantly (p < 0.001 for all). Similarly, the rates of hospitalized days decreased for HF and cardiovascular causes (p < 0.05 for all). Following TMVr, the odds of having no Medicare costs for HF hospitalizations increased (69% vs. 79%; odds ratio: 1.67; p < 0.001). However, the average total Medicare costs per day alive among patients with any HF hospitalizations after TMVr increased significantly (p < 0.001). The HF hospitalization rates decreased for patients with functional MR (683 vs. 502; RR: 0.74) and those with degenerative MR (431 vs. 337; RR: 0.78) (p < 0.001).
CONCLUSIONS:
TMVr is associated with a decrease in cardiovascular and HF hospitalizations and a greater likelihood of having no HF Medicare costs in the year after TMVr, regardless of MR etiology. Further work is necessary to elucidate the reasons for increased costs among patients with HF hospitalizations post-TMVr.
Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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Epoxyeicosatrienoic acid prevents maladaptive remodeling in pressure overload by targeting calcineurin/NFAT and Smad-7.
Exp Cell Res2019 Nov;():111716. doi: S0014-4827(19)30595-6.
Li Xuguang, Chu Guang, Zhu Feng, Zheng Zhifeng, Wang Xiang, Zhang Guobing, Wang Fang,
Abstract
BACKGROUND:
Emerging evidence demonstrates that epoxyeicosatrienoic acids (EETs) as important active eicosanoids that regulate cardiovascular homeostasis, but the mechanisms underlying its favorable anti-hypertrophic benefits in overpressure model remain obscure.
METHODS AND RESULTS:
Four weeks after transverse aortic constriction (TAC), TAC mice developed maladaptive cardiac hypertrophy and consequent cardiac failure. Conversely, a cardiotropic adeno-associated viral vector (AAV9) encoding CYP2J2 prevented transverse aortic constriction-induced cardiac hypertrophy with preserved ejection fraction. EET also conferred protection against phenylephrine-induced hypertrophy in H9c2 cardiomyoblasts. Further investigations indicate CYP2J2/EET exerts protection against cardiac hypertrophy through opposing the increase of intracellular Ca level and Ca-mediated calcineurin/NFATc3 signaling. Meanwhile, extended myocardial fibrosis in TAC mice was also effectively abolished with the administration of AAV9-2J2. Intriguingly, TAC mice display activated TGF-?/Samd-3 signaling with decreased Smad-7 expression, whereas AAV9-2J2 attenuated the phosphorylation of Smad-3 without altering TGF-? expression, whilst preservation of Smad-7. Subsequently, the differentiation of cardiac fibroblasts into myofibroblasts in the presence of TGF-?1 stimulation was significantly disrupted with EET treatment, accompanied by declined Smad-3 activation and collagen production, whereas inhibition of Smad-7 with SiRNA Smad-7 substantially abrogated these effects of EET on cardiac fibroblasts.
CONCLUSIONS:
EET has synergistic actions on cardiomyocytes and cardiac fibroblasts, preventing cardiac hypertrophy through inhibition of Ca-mediated calcineurin/NFATc3 signaling cascades, and ameliorating myocardial fibrosis dependent on Smad-7. This work further extends the potential mechanisms of EET, providing a novel therapeutic approach for the treatment of pathological remodeling and heart failure.
Copyright © 2019. Published by Elsevier Inc.
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Coronary angiography in the setting of acute infective endocarditis requiring surgical treatment.
Arch Cardiovasc Dis2019 Nov;():. doi: S1875-2136(19)30173-1.
Laperche Clémence, Lairez Olivier, Ferrieres Jean, Robin Guillaume, Gautier Mathieu, Badie Yoan Lavie, Lhermusier Thibault, Boudou Nicolas, Campelo-Parada Francisco, Roncalli Jérôme, Marcheix Bertrand, Galinier Michel, Elbaz Meyer, Carrié Didier, Bouisset Frédéric,
Abstract
BACKGROUND:
International guidelines recommend that preoperative coronary angiography is performed on patients at risk of coronary disease who have infective endocarditis requiring surgical treatment. However, the risks of contrast-induced nephropathy or vegetation embolization in case of aortic endocarditis should be considered.
AIMS:
To assess the safety, therapeutic implications and prognostic impact of coronary angiography in patients requiring surgical treatment for active infective endocarditis.
METHODS:
This retrospective monocentric study was conducted in patients referred to a tertiary care centre for active endocarditis management with a theoretical indication for surgery between January 2013 and February 2017.
RESULTS:
One hundred and ninety-three patients were included; 73.1% were men, the mean age was 61.9±16.3 years and the median EuroSCORE II was 5.8%. One hundred and nineteen patients (61.7%) had aortic endocarditis, which was associated with aortic vegetation in 74 cases (38.3%). Invasive coronary angiography was performed in 142 patients (73.6%) - 130 (91.6%) by radial approach - and 14 patients were evaluated by coronary multislice computed tomography (one patient had exploration with both techniques). Acute renal failure after coronary angiography was observed in 15 patients (10.6%), two patients (1.4%) presented a stroke within 24h after coronary angiography, but none had aortic endocarditis. Among the 178 patients (92.2%) who underwent surgery, 35 (19.7%) had significant coronary lesion(s) and 25 (14.0%) underwent an associated coronary artery bypass graft.
CONCLUSIONS:
Preoperative coronary angiography in patients affected by infective endocarditis provides relevant information in a significant proportion of patients and can be performed safely.
Copyright © 2019 Elsevier Masson SAS. All rights reserved.
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Management of sustained arrhythmias for patients with cardiogenic shock in intensive cardiac care units.
Arch Cardiovasc Dis2019 Nov;():. doi: S1875-2136(19)30169-X.
Maury Philippe, Mansourati Jacques, Fauchier Laurent, Waintraub Xavier, Boveda Serge, Sacher Frederic,
Abstract
Cardiac arrhythmias that occur in patients referred to intensive care units worsen symptoms and outcomes and need urgent correction, especially in patients admitted for refractory heart failure. Electrical storm is a frequent reason for referral to an intensive care unit. Specific, efficient and rapid management of patients presenting with various arrhythmias is therefore mandatory and procedures should be known by any physician involved in an intensive care unit. This article reviews the current knowledge on the management of supraventricular and ventricular arrhythmias in this setting, from medications and sedation to ablation and more exceptional therapy. It also covers the occasional indications of resynchronization in refractory heart failure and the interest for haemodynamic assistance when specific therapy fails.
Copyright © 2019 Elsevier Masson SAS. All rights reserved.
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Improving growth of infants with congenital heart disease using a consensus-based nutritional pathway.
Clin Nutr2019 Nov;():. doi: S0261-5614(19)33124-3.
Marino Luise V, Johnson Mark J, Davies Natalie J, Kidd Catherine S, Fienberg Julie, Richens Trevor, Bharucha Tara, Beattie R Mark, Darlington Anne-Sophie E,
Abstract
OBJECTIVE:
Infants with congenital heart disease (CHD) often experience growth failure prior to surgery, which is associated with increased paediatric-intensive-care unit length of stay (PICU-LOS) and post-operative complications. This study assessed the impact of a pre-operative, consensus-based nutritional pathway (including support from a multi-disciplinary team) on growth and clinical outcome.
DESIGN:
Single-centre prospective pilot study.
SETTING:
Tertiary paediatric cardiology surgical centre.
PATIENTS:
Infants with CHD.
INTERVENTION:
Infants with CHD were followed for up to 4-months-of-age before cardiac surgery and then to 12-months-of-age following the implementation of the consensus-based nutritional-pathway (Intervention group: November 2017-August 2018), with outcomes compared to a historic control group. The nutrition pathway involved a dietitian contacting parents of infants with the highest risk of growth failure weekly; reviewing weight gain and providing feeding support.
MAIN OUTCOME MEASURE:
Growth (weight-for-age, WAZ, and height-for-age-z-score, HAZ) at 4 and 12 months-of-age.
RESULTS:
44 infants in the intervention group were compared to 38 in the control group. Median (inter quartile range) change in WAZ from birth to 4 months-of-age (-0.9 (-1.5, 0.7)) and from birth to 12 months-of-age (-0.09 (-1.3, 1.1)) in the intervention group compared to the control group (-1.5 (-2.0, -0.4) (p = 0.04)) at 4 months-of age and at 12 months-of-age (-0.4 (1.9, 0.2) (p = 0.03)). HAZ at 4 months-of-age was -0.7 (-1.4, -0.1) vs. -1.0 (-1.9, -0.3) (p = 0.6) in the intervention and control groups respectively, and at 12 months-of-age HAZ was -0.7 (-1.9, -0.07) in the intervention group vs.-1.6 (-2.6, -0.4) in the control group (p = 0.04). Duration of PICU-LOS was 8.2 ± 11.6 days intervention vs. 18.3 ± 24.0 days control (p = 0.006).
CONCLUSION:
Overall weight was well maintained and growth improved in infants who followed the pre-operative nutritional-pathway. The duration of PICU-LOS was significantly lower in the intervention group, which may be due to improved nutritional status, although this requires further investigation.
Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.
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Early and late outcomes following aortic root enlargement: A multicenter propensity score-matched cohort analysis.
J Thorac Cardiovasc Surg2019 Sep;():. doi: S0022-5223(19)32066-5.
Tam Derrick Y, Dharma Christoffer, Rocha Rodolfo V, Ouzounian Maral, Wijeysundera Harindra C, Austin Peter C, Fremes Stephen E,
Abstract
OBJECTIVE:
The safety and efficacy of aortic root enlargement (ARE) at the time of aortic valve replacement (AVR) remains unknown. The objective of this multicenter study was to compare AVR with ARE to AVR for early and late mortality and secondary safety outcomes.
METHODS:
Clinical and administrative databases in Ontario, Canada, were linked to obtain patients undergoing AVR with or without ARE from 2008 to 2017. Baseline characteristics were compared and 1:1 propensity score matching was performed to account for differences in baseline characteristics. Early outcomes were compared in the matched groups. Late mortality was compared using Kaplan-Meier survival curves and a Cox-proportional hazard model.
RESULTS:
Sixteen thousand six hundred fifty-six patients undergoing AVR in 11 Ontario institutions were reviewed. Patients who underwent ARE were younger, nonurgent, more likely to be men and had lower rates of hypertension, ischemic heart disease, and congestive heart failure. Propensity score matching yielded similar groups for comparison, with 809 pairs for AVR versus AVR with ARE. There was no difference in 30-day mortality between AVR with ARE versus AVR (2.0% vs 2.1%; P = 1.00). Rates of chest reopening for bleeding, permanent pacemaker implantation, and blood transfusions were similar. Late mortality over 8 years was similar between AVR with ARE and AVR (P = .45). In a sensitivity analysis, results were similar in 525 pairs comparing AVR with coronary artery bypass grafting and ARE to AVR with coronary artery bypass grafting, except that chest reopening for bleeding was higher with AVR with coronary artery bypass grafting and ARE (7.2% vs 3.2%; P = .006).
CONCLUSIONS:
The addition of ARE to isolated AVR can be safely performed to increase implanted prosthesis size without compromising early mortality. Additional studies with longer follow-up are necessary.
Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.
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The Impact of Donor Origin on Survival After Orthotopic Heart Transplantation.
Transplant Proc2019 Nov;():. doi: S0041-1345(19)30572-X.
Kiamanesh Omid, Khosla Amit, Johansson Erica, Virani Sean, Davis Margot, Cheung Anson, Bashir Jamil, Munt Bradley, Ignaszewski Andrew, Kaan Annemarie, Toma Mustafa,
Abstract
Heart transplantation is the definitive management for select patients with end-stage heart failure. Owing to an ongoing organ donor shortage, organs are sometimes allocated from distant locales. These organs may be perceived as less desirable because of donor risk factors and ischemic times. We compared survival after heart transplantation by donors originating from British Columbia (BC), other Canadian provinces, and the United States. This retrospective cohort analysis included all patients transplanted in BC between December 1, 1988, and October 21, 2014, and excluded those with missing data or retransplantation. Among 382 patients, 297 (77.7%) recipients and 238 (62.3%) donors were male. The median recipient age was 54.6 years (interquartile range, 46.0-61.0 years) and the median donor age was 33 years (interquartile range, 22-46 years). Overall 10-year survival was 62.1% (95% confidence interval, 56.3-67.4). There was no difference in 10-year survival when comparing donors from BC, other Canadian provinces, and the United States despite significantly lower median ischemic times in donors from BC. Donor location was not predictive of mortality after controlling for recipient age, donor age, and cold ischemic time. Donor origin did not impact 10-year survival after heart transplantation despite increased ischemic time, suggesting that distant donors result in similar outcomes in BC.
Copyright © 2019 Elsevier Inc. All rights reserved.
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Effect of Testosterone Level on Mortality in Patients With Left Ventricular Assist Device.
Transplant Proc2019 Nov;():. doi: S0041-1345(19)30923-6.
Simsek Evrim, Kilic Salih, Kemal Hatice Soner, Nalbantgil Sanem, Ozturk Pelin, Yildirim Ilgin, Yagdi Tahir, Engin Cagatay, Ozbaran Mustafa,
Abstract
BACKGROUND AND OBJECTIVES:
Testosterone deficiency is associated with mortality in patients with heart failure; however, its effects on patients undergoing Left Ventricular Assist Device (LVAD) implantation are unclear. We investigated the role of total testosterone (TT) and free testosterone (FT) levels on mortality undergoing LVAD implantation.
METHODS:
Between December 2010 and December 2014, 101 consecutive male patients who underwent LVAD implantation and had plasma testosterone measurement (TT and FT) in the last month before operation were included in the study. Demographics, follow-up, and mortality data were analyzed retrospectively.
RESULTS:
The mean age of the patients was 51.7 ± 11 years. TT and FT levels were in the below normal range of 31.6% (n = 32) and 65.3% (n = 66) of the patients, respectively. The mean follow-up time was 355 ± 268 days, and 32 (31%) patients died during follow-up. Cumulative survival rates were significantly worse in patients with low TT and FT than patients in the normal range (P < .001 and P = .029, respectively). Multivariate analysis after adjustment for clinical variables, age, albumin, C-reactive protein, total cholesterol, chronic kidney disease, diabetes mellitus (DM), and leukocytosis showed that low TT and FT were independently associated with poor survival (HR, 3.680; 95% CI, 1.615-8.385 P = .002 and HR, 3.816; 95% CI, 1.279-11.383, P = .016, respectively).
CONCLUSION:
Low TT and FT levels were independent risk factors for mortality in patients with LVAD.
Copyright © 2019 Elsevier Inc. All rights reserved.
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Optimizing Transradial Access: Radiation, Contrast, Access Site Crossover, and Ergonomics.
Interv Cardiol Clin2020 Jan;9(1):99-105. doi: S2211-7458(19)30056-2.
Safirstein Jordan G,
Abstract
This article summarizes the data comparing radiation exposure and contrast use between transradial and transfemoral cardiac catheterizations. It also reviews the important features that may predict access site failure and crossover. In addition, it reviews the concept of ergonomics in the catheterization laboratory and how clinicians can improve the transradial approach.
Copyright © 2019 Elsevier Inc. All rights reserved.
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Orthostatic Hypotension in Parkinson Disease.
Clin Geriatr Med2020 Feb;36(1):53-67. doi: S0749-0690(19)30077-1.
Palma Jose-Alberto, Kaufmann Horacio,
Abstract
Orthostatic hypotension (OH) is a sustained fall in blood pressure on standing that can cause symptoms of organ hypoperfusion. OH is associated with increased morbidity and mortality and leads to a significant number of hospital admissions. OH can be caused by volume depletion, blood loss, cardiac pump failure, large varicose veins, medications, or defective activation of sympathetic nerves and reduced norepinephrine release upon standing. Neurogenic OH is a frequent and disabling problem in patients with synucleinopathies such as Parkinson disease, multiple system atrophy, and pure autonomic failure, and it is commonly associated with supine hypertension. Several therapeutic options are available.
Copyright © 2019 Elsevier Inc. All rights reserved.
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Risk of early mortality and cardiovascular disease in type 1 diabetes: a comparison with type 2 diabetes, a nationwide study.
Cardiovasc Diabetol2019 Nov;18(1):157. doi: 10.1186/s12933-019-0953-7.
Lee You-Bin, Han Kyungdo, Kim Bongsung, Lee Seung-Eun, Jun Ji Eun, Ahn Jiyeon, Kim Gyuri, Jin Sang-Man, Kim Jae Hyeon,
Abstract
BACKGROUND:
Both type 1 and type 2 diabetes are well-established risk factors for cardiovascular disease and early mortality. However, few studies have directly compared the hazards of cardiovascular outcomes and premature death among people with type 1 diabetes to those among people with type 2 diabetes and subjects without diabetes. Furthermore, information about the hazard of cardiovascular disease and early mortality among Asians with type 1 diabetes is sparse, although the clinical and epidemiological characteristics of Asians with type 1 diabetes are unlike those of Europeans. We estimated the hazard of myocardial infarction (MI), hospitalization for heart failure (HF), atrial fibrillation (AF), and mortality during follow-up in Korean adults with type 1 diabetes compared with those without diabetes and those with type 2 diabetes.
METHODS:
We used Korean National Health Insurance Service datasets of preventive health check-ups from 2009 to 2016 in this retrospective longitudinal study. The hazard ratios of MI, HF, AF, and mortality during follow-up were analyzed using the Cox regression analyses according to the presence and type of diabetes in ??20-year-old individuals without baseline cardiovascular disease (N?=?20,423,051). The presence and type of diabetes was determined based on the presence of type 1 or type 2 diabetes at baseline.
RESULTS:
During more than 93,300,000 person-years of follow-up, there were 116,649 MIs, 135,532 AF cases, 125,997 hospitalizations for HF, and 344,516 deaths. The fully-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for incident MI, hospitalized HF, AF, and all-cause death within the mean follow-up of 4.6 years were higher in the type 1 diabetes group than the type 2 diabetes [HR (95% CI) 1.679 (1.490-1.893) for MI; 2.105 (1.901-2.330) for HF; 1.608 (1.411-1.833) for AF; 1.884 (1.762-2.013) for death] and non-diabetes groups [HR (95% CI) 2.411 (2.138-2.718) for MI; 3.024 (2.730-3.350) for HF; 1.748 (1.534-1.993) for AF; 2.874 (2.689-3.073) for death].
CONCLUSIONS:
In Korea, the presence of diabetes was associated with a higher hazard of cardiovascular disease and all-cause death. Specifically, people with type 1 diabetes had a higher hazard of cardiovascular disease and all-cause mortality compared to people with type 2 diabetes.
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Diagnostic tools for early detection of cardiac dysfunction in childhood cancer survivors: Methodological aspects of the Dutch late effects after childhood cancer (LATER) cardiology study.
Am Heart J2019 Nov;219():89-98. doi: S0002-8703(19)30292-3.
Leerink Jan M, Feijen E Lieke A M, van der Pal Helena J H, Kok Wouter E M, Mavinkurve-Groothuis Annelies M C, Kapusta Livia, Pinto Yigal M, Maas Angela H E M, Bellersen Louise, Teske Arco J, Ronckers Cécile M, Louwerens Marloes, van Dalen Elvira C, van Dulmen-den Broeder Eline, Batenburg Lilian, van der Heiden-van der Loo Margriet, van den Heuvel-Eibrink Marry M, van Leeuwen Flora E, de Vries Andrica C H, Weijers Gert, de Korte Chris L, Loonen Jacqueline J, Neggers Sebastian J C M M, Versluys A B Birgitta, Tissing Wim J E, Kremer Leontien C M, ,
Abstract
BACKGROUND:
Cancer therapy-related cardiac dysfunction and heart failure are major problems in long-term childhood cancer survivors (CCS). We hypothesize that assessment of more sensitive echo- and electrocardiographic measurements, and/or biomarkers will allow for improved recognition of patients with cardiac dysfunction before heart failure develops, and may also identify patients at lower risk for heart failure.
OBJECTIVE:
To describe the methodology of the Dutch LATER cardiology study (LATER CARD).
METHODS:
The LATER CARD study is a cross-sectional study in long-term CCS treated with (potentially) cardiotoxic cancer therapies and sibling controls. We will evaluate 1) the prevalence and associated (treatment related) risk factors of subclinical cardiac dysfunction in CCS compared to sibling controls and 2) the diagnostic value of echocardiography including myocardial strain and diastolic function parameters, blood biomarkers for cardiomyocyte apoptosis, oxidative stress, cardiac remodeling and inflammation and ECG or combinations of them in the surveillance for cancer therapy-related cardiac dysfunction. From 2017 to 2020 we expect to include 1900 CCS and 500 siblings.
CONCLUSIONS:
The LATER CARD study will provide knowledge on different surveillance modalities for detection of cardiac dysfunction in long-term CCS at risk for heart failure. The results of the study will enable us to improve long-term follow-up surveillance guidelines for CCS at risk for heart failure.
Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.
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Positive Fluid Balance and Association with Post-Traumatic Acute Kidney Injury.
J Am Coll Surg2019 Nov;():. doi: S1072-7515(19)32169-6.
Hatton Gabrielle E, Du Reginald E, Wei Shuyan, Harvin John A, Finkel Kevin W, Wade Charles E, Kao Lillian S,
Abstract
BACKGROUND:
Acute kidney injury (AKI) is common in severely injured trauma patients and is associated with poor outcomes. A positive fluid balance is associated with AKI and poor long-term renal outcomes among general intensive care unit (ICU) and cardiac surgery patients. Currently, the optimal endpoint of resuscitation of severely injured trauma patients is unknown, which may result in excess fluid administration. We hypothesized that positive fluid balance is common after severe trauma and is associated with increased AKI development.
DESIGN:
A cohort study of adult (?16 years) trauma patients requiring ICU admission from January 2017 to June of 2017 was conducted. Patients were excluded for early death, rhabdomyolysis, or prior history of end-stage renal disease or congestive heart failure. AKI within 7 days of admission was defined according to Kidney Disease Improving Global Outcomes creatinine-based criteria. Univariate and multivariable analyses were performed.
RESULTS:
Of 364 patients, 74% were male. The median age was 41 years (IQR 27-59) and the median injury severity score (ISS) was 18 (IQR 10-29). Positive fluid balance (>2L) was observed in 49% of patients. AKI was diagnosed in 105 (29%) patients. After adjustment, there was an increased risk of AKI with a positive fluid balance >2L (RR 1.98 (95% CI 1.24-3.17)). Additionally, the risk of AKI incrementally increased by 1.22 with each liter fluid positive above a zero balance (95% CI 1.11-1.34).
CONCLUSIONS:
Positive fluid balance in excess of 2L at 48-hours occurs in half of severely injured trauma patients and fluid positivity is independently and incrementally associated with AKI development. Fluid responsiveness should be investigated as an end point of post-traumatic resuscitation to prevent unnecessary fluid administration and subsequent AKI.
Copyright © 2019. Published by Elsevier Inc.
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Persistent atrial fibrillation in heart failure with preserved ejection fraction: prognostic relevance and association with clinical, imaging, and invasive hemodynamic parameters.
Eur J Clin Invest2019 Nov;():e13184. doi: 10.1111/eci.13184.
Schönbauer Robert, Duca Franz, Kammerlander Andreas A, Aschauer Stefan, Binder Christina, Zotter-Tufaro Caroline, Koschutnik Matthias, Fiedler Lukas, Xaver Roithinger Franz, Loewe Christian, Hengstenberg Christian, Bonderman Diana, Mascherbauer Julia,
Abstract
BACKGROUND:
AF is a frequent finding in HFpEF. However, its association with invasive hemodynamics, imaging parameters, and outcome in HFpEF is not well established. Furthermore, the relevance of AF subtype with regard to outcome is unclear. This study sought to investigate the prognostic impact of paroxysmal and persistent atrial fibrillation (AF) in a well defined heart failure with preserved ejection fraction (HFpEF) population.
MATERIALS AND METHODS:
Between 2010 and 2016 254 HFpEF patients were prospectively enrolled. All patients underwent echocardiography as well as left and right heart catheterization. Patients without contraindications underwent CMR including T1 mapping. Follow up and outcome data were collected. Patients with significant coronary artery disease were excluded.
RESULTS:
153 patients (60%) suffered from AF, 119 (47%) had persistent and 34 (13%) had paroxysmal AF. By multiple logistic regression analysis, persistent AF was independently associated with NT-proBNP (p=0.003), NYHA functional class (p=0.040), left and right atrial size (p=0.022 and <0.001, respectively), cardiac output (p=0.002), and COPD (p=0.034). After a median follow-up of 23 months (interquartile range 5-48) 92 patients (36%) reached the primary endpoint defined as hospitalization for heart failure or cardiovascular death. By multivariate Cox regression analysis, only persistent AF (p=0.005) and six-minute walk distance (p=0.011) were independently associated with the primary endpoint.
CONCLUSIONS:
60% of our HFpEF patients suffered from AF. Persistent but not paroxysmal AF was strongly associated with event-free survival and was independently related with NYHA functional class, serum NT-proBNP, atrial size, cardiac ouput, and presence of COPD.
© 2019 Stichting European Society for Clinical Investigation Journal Foundation.
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Prenatal Identification of Restrictive and Non-restrictive Ventricular Septal Defects Based on End-Systolic Flow Patterns in the Fetal Aortic Isthmus.
Pediatr Cardiol2019 Nov;():. doi: 10.1007/s00246-019-02257-2.
Fouron Jean-Claude, Thomas-Chabaneix Julie, Brisebois Sophie, Berger Annie, Dahdah Nagib,
Abstract
Fetuses with large ventricular septal defects (VSDs) must be closely monitored during the perinatal period. Intrauterine assessment of size of septal defects with bidimensional echocardiography are unreliable. The objective of the present study is to document the contribution of flow pattern analysis in the fetal aortic isthmus for prenatal identification of large non-restrictive VSDs requiring immediate postnatal attention. We conducted a cross-sectional retrospective study of Doppler recordings from patients referred to our Fetal Cardiology Unit and diagnosed with one or multiple VSDs from January 2006 to November 2015. Three groups were defined: (1) large non-restrictive VSDs (n?=?11) with postnatal cardiac failure (2) small restrictive VSDs (n?=?28) asymptomatic, and (3) absence of cardiac abnormality (n?=?66). The Isthmic end-Systolic Index (ISI) was computed to quantify aortic isthmus flow and compared between the three groups. Fetuses with restrictive VSD and control group showed similar ISI: stable at 0.20?±?0.01 up to 27 weeks of gestation and dropping later due to the fall of end-systolic velocities in the aortic isthmus. By 35 weeks, a brief end-systolic retrograde flow was present, associated with a further fall of ISI down to -0.26?±?0.05. In contrast, ISI of fetuses with large non-restrictive VSDs were unchanged throughout gestation (0.18?±?0.06), becoming significantly higher during the last weeks of gestation compared to the two other groups (p?
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