Advanced heart failure patients supported with ambulatory inotropic therapy: What defines success of therapy?

OBJECTIVE

The objective of this study was to describe the profiles and outcomes of a cohort of advanced heart failure patients on ambulatory inotropic therapy (AIT).

BACKGROUND

With the growing burden of patients with end-stage heart failure, AIT is an increasingly common short or long-term option, for use as bridge to heart transplant (BTT), bridge to ventricular assist device (BTVAD), bridge to decision regarding advanced therapies (BTD) or as palliative care. AIT may be preferred by some patients and physicians to facilitate hospital discharge. However, counseling patients on risks and benefits is critically important in the modern era of defibrillators, durable mechanical support and palliative care.

METHODS

We retrospectively studied a cohort of 241 patients on AIT. End points included transplant, VAD implantation, weaning of inotropes, or death. The primary outcomes were survival on AIT and ability to reach intended goal if planned as BTT or BTVAD. We also evaluated recurrent heart failure hospitalizations, incidence of ventricular arrhythmias (VT/VF) and indwelling line infections. Unintended consequences of AIT, such reaching unintended end point (e.g. VAD implantation in BTT patient) or worse than expected outcome after LVAD or HT, were recorded.

RESULTS

Mean age of the cohort was 60.7 ± 13.2 years, 71% male, with Class III-IV heart failure (56% non-ischemic). Average ejection fraction was 19.4 ± 10.2%, pre-AIT cardiac index was 1.5 ± 0.4 L/min/m² and 24% had prior ventricular arrhythmias. Overall on-AIT 1-year survival was 83%. Hospitalizations occurred in 51.9% (125) of patients a total of 174 times for worsening heart failure, line complication or ventricular arrhythmia. In the BTT cohort, only 42% were transplanted by the end of follow-up, with a 14.8% risk of death or delisting for clinical deterioration. For the patients who were transplanted, 1-year post HT survival was 96.7%. In the BTVAD cohort, 1-year survival after LVAD was 90%, but with 61.7% of patients undergoing LVAD as INTERMACS 1-2. In the palliative care cohort, only 24.5% of patients had a formal palliative care consult prior to AIT.

CONCLUSIONS

AIT is a strategy to discharge advanced heart failure patients from the hospital. It may be useful as bridge to transplant or ventricular assist device, but may be limited by complications such as hospitalizations, infections, and ventricular arrhythmias. Of particular note, it appears more challenging to bridge to transplant on AIT in the new allocation system. It is important to clarify the goals of AIT therapy upfront and continue to counsel patients on risks and benefits of the therapy itself and potential unintended consequences. Formalized, multi-disciplinary care planning is essential to clearly define individualized patient, as well as programmatic goals of AIT.

Outcome of Sars-COV-2-related thyrotoxicosis in survivors of Covid-19: a prospective study

PURPOSE

To evaluate the post- coronavirus disease-19 (COVID-19) outcome of thyroid function in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related thyrotoxicosis.

METHODS

This was a single-center prospective study involving 29 patients (11 females, 18 males; median age 64 years, range: 43-85) with thyrotoxicosis diagnosed after hospitalization for COVID-19 and then followed-up for a median period of 90 days (range: 30-120) after hospital discharge. At follow-up, patients were evaluated for serum thyrotropin (TSH), free-thyroxine (FT4), free-triiodiothyronine (FT3), TSH receptor antibodies (TRAb), thyroglobulin antibodies (TgAb), thyroperoxidase antibodies (TPOAb) and ultrasonographic thyroid structure.

RESULTS

After recovery of COVID-19, serum TSH values significantly increased (P < 0.001) and FT4 values significantly decreased (P = 0.001), without significant change in serum FT3 (P = 0.572). At follow-up, 28 subjects (96.6%) became euthyroid whereas overt hypothyroidism developed in one case. At the ultrasound evaluation of thyroid gland, hypoecogenicity was found in 10 patients (34.5%) and in these cases serum TSH values tended to be higher than those without thyroid hypoecogenity (P = 0.066). All subjects resulted to be negative for TgAb, TPOAb and TRAb.

CONCLUSION

In a short-term follow-up, thyroid function spontaneously normalized in most subjects with SARS-CoV-2-related thyrotoxicosis. However, thyroid hypoecogenicity was found in a remarkable number of them and future longer-term studies are needed to clarify whether this ultrasonographic alteration may predispose to develop late-onset thyroid dysfunction.

Burden of disease from exposure to secondhand smoke in children in Europe

BACKGROUND

Secondhand smoke (SHS) exposure at home and fetal SHS exposure during pregnancy are a major cause of disease among children. The aim of this study is quantifying the burden of disease due to SHS exposure in children and in pregnancy in 2006-2017 for the 28 European Union (EU) countries.

METHODS

Exposure to SHS was estimated using a multiple imputation procedure based on the Eurobarometer surveys, and SHS exposure burden was estimated with the comparative risk assessment method using meta-analytical relative risks. Data on deaths and disability-adjusted life years (DALYs) were collected from National statistics and from the Global Burden of Disease Study.

RESULTS

Exposure to SHS and its attributable burden stalled in 2006-2017; in pregnant women, SHS exposure was 19.8% in 2006, 19.1% in 2010, and 21.0% in 2017; in children it was 10.1% in 2006, 9.6% in 2010, and 12.1% in 2017. In 2017, 35,633 DALYs among children were attributable to SHS exposure in the EU, mainly due to low birth weight.

CONCLUSIONS

Comprehensive smoking bans up to 2010 contributed to reduce SHS exposure and its burden in children immediately after their implementation; however, SHS exposure still occurs, and in 2017, its burden in children was still relevant.

IMPACT

Exposure to secondhand smoke at home and in pregnancy is a major cause of disease among children. Smoking legislation produced the adoption of voluntary smoking bans in homes; however, secondhand smoke exposure at home still occurs and its burden is substantial. In 2017, the number of deaths and disability-adjusted life years in children attributable to exposure to secondhand smoke in the European Union countries were, respectively, 335 and 35,633. Low birth weight caused by secondhand smoke exposure in pregnancy showed the largest burden. Eastern European Union countries showed the highest burden.

Predicting survival in patients with acute decompensated heart failure complicated by cardiogenic shock

Background

Acute decompensated heart failure (ADHF) complicated by cardiogenic shock (CS) has unique pathophysiological background requiring specific patient stratification, management and therapeutic targets. Accordingly, the aim of this study was to derive a simple stratification tool to predict survival in patients with ADHF complicated by CS.

Methods and results

Using logistic regression, univariable testing was performed to identify the variables potentially associated with 28-day mortality. We propose a new logistic model (ALC-Shock score) based on three easy parameters (age, serum creatinine and serum lactate at the ICU admission) as a powerful predictor of survival or successful bridge to heart replacement therapy at 28-day follow-up in this specific population. A multivariable analysis (logistic model) was performed to evaluate the association between selected variables and outcome (overall death at 28-day follow up). The score was then validated in a different cohort of 93 ADHF-CS patients and compared to a previous developed score (the Cardshock score).Overall, 28-day mortality was 34%. The ALC-shock score showed better discrimination (Area Under the Curve-AUC- 0.82; 95% CI 0.73-0.91) as compared to the Cardshock score (AUC 0.67; 95% CI 0.55-0.79) (p = 0.009) to predict 28-days overall mortality. In the validation cohort the AUC for the ALC-shock score was 0.66.

Conclusions

A simple score including age, lactates and creatinine on admission could be considered to predict short-term mortality in CS-ADHF patients in order to drive towards a treatment intensification.

Safety of 3-FL (3-Fucosyllactose) as a novel food pursuant to Regulation (EU) 2015/2283

Following a request from the European Commission, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was asked to deliver an opinion on 3-fucosyllactose (3-FL) as a novel food (NF) pursuant to Regulation (EU) 2015/2283. The NF is mainly composed of the human-identical milk oligosaccharide (HiMO) 3-FL but also contains D-lactose and its monomers, L-fucose and a small fraction of other related saccharides. The NF is produced by fermentation with a genetically modified strain of Escherichia coli K-12. The information provided on the manufacturing process, composition and specifications of the NF does not raise safety concerns. The applicant intends to add the NF in a variety of foods, including infant and follow-on formula, foods for infants and toddlers, foods for special medical purposes and food supplements. The target population is the general population, except for food supplements for which the target population is individuals above 1 year of age. The anticipated daily intake of 3-FL from the NF at the maximum proposed use levels is unlikely to exceed the intake level of breastfed infants on a body weight basis. The intake of 3-FL in breastfed infants on a body weight basis is expected to be safe also for other population groups. In infants below 1 year of age, a possible exceedance of a natural intake was observed, but the degree of this exceedance is not considered of safety concern in view of the wide range of 3-FL concentrations in human milk. Food supplements are not intended to be used if other foods with the added NF (as well as human milk for young children) are consumed on the same day. The Panel concludes that the NF is safe under the proposed conditions of use.

2,2'4,4'-Tetrabromodiphenyl Ether (PBDE-47) Modulates the Intracellular miRNA Profile, sEV Biogenesis and Their miRNA Cargo Exacerbating the LPS-Induced Pro-Inflammatory Response in THP-1 Macrophages

The 2,2’4,4’-tetrabromodiphenyl ether (PBDE-47) is one of the most prominent PBDE congeners detected in the environment and in animal and human tissues. Animal model experiments suggested the occurrence of PBDE-induced immunotoxicity leading to different outcomes and recently we demonstrated that this substance can impair macrophage and basophil activities. In this manuscript, we decided to further examine the effects induced by PBDE-47 treatment on innate immune response by looking at the intracellular expression profile of miRNAs as well as the biogenesis, cargo content and activity of human M(LPS) macrophage cell-derived small extracellular vesicles (sEVs). Microarray and in silico analysis demonstrated that PBDE-47 can induce some epigenetic effects in M(LPS) THP-1 cells modulating the expression of a set of intracellular miRNAs involved in biological pathways regulating the expression of estrogen-mediated signaling and immune responses with particular reference to M1/M2 differentiation. In addition to the cell-intrinsic modulation of intracellular miRNAs, we demonstrated that PBDE-47 could also interfere with the biogenesis of sEVs increasing their number and selecting a de novo population of sEVs. Moreover, PBDE-47 induced the overload of specific immune related miRNAs in PBDE-47 derived sEVs. Finally, culture experiments with naïve M(LPS) macrophages demonstrated that purified PBDE-47 derived sEVs can modulate macrophage immune response exacerbating the LPS-induced pro-inflammatory response inducing the overexpression of the IL-6 and the MMP9 genes. Data from this study demonstrated that PBDE-47 can perturb the innate immune response at different levels modulating the intracellular expression of miRNAs but also interfering with the biogenesis, cargo content and functional activity of M(LPS) macrophage cell-derived sEVs.

Remote Monitoring of Heart Transplant Recipients during the COVID-19 Pandemic

Purpose

The COVID-19 pandemic created significant challenges in monitoring heart transplant (HT) recipients for rejection due to efforts to minimize contact with the hospital setting. The aim of this study was to evaluate the safety and efficacy of transitioning HT patients to home phlebotomy and a monitoring protocol based on gene expression profiling (GEP) and donor derived cell free DNA (ddcfDNA).

Methods

A single-center cohort study that prospectively enrolled consecutive HT patients who were transitioned to a remote monitoring protocol employing home phlebotomy and non-invasive surveillance for rejection. Patients were enrolled starting at 2 months post-HT. Positive GEP values were defined as ≥32 (up to 6 months post-HT) and ≥34 (> 6 months post-HT). A positive ddcfDNA score was defined as >0.12%. A positive biopsy was defined as grade ≥1B/1R

Results

246 HT patients were enrolled and followed for a minimum of 3 months. Mean age was 56±14, 71.5% were male, and median time from transplant was 2.7 years. The average distance of patients from the hospital was 25.6 miles. 359 blood tests were drawn for detection of GEP and ddcfDNA and 102 biopsies performed (Figure). Among 32 patients who had negative results on both tests and had a biopsy, 0 had a positive biopsy. Of 25 patients who had positive results on both tests and had a biopsy, 3 (12%) had a positive biopsy. The biopsy positivity rate in patients who were GEP+/ddcfDNA- was 6% and in patients who were GEP-/ddcfDNA+ was 8%. None of the positive biopsies were associated with hemodynamic compromise. 15 (6%) of patients were admitted due to allograft rejection during the study period. There were no deaths.

Conclusion

Using a remote monitoring protocol with home phlebotomy and noninvasive rejection surveillance was feasible and safe in HT recipients. In this cohort, the combination of negative GEP and ddcfDNA scores was accurate at predicting a lack of allograft rejection.

Who Smokes in Europe? Data From 12 European Countries in the TackSHS Survey (2017-2018)

BACKGROUND

Population data on tobacco use and its determinants require continuous monitoring and careful inter-country comparison. We aimed to provide the most up-to-date estimates on tobacco smoking from a large cross-sectional survey, conducted in selected European countries.

METHODS

Within the TackSHS Project, a face-to-face survey on smoking was conducted in 2017-2018 in 12 countries: Bulgaria, England, France, Germany, Greece, Ireland, Italy, Latvia, Poland, Portugal, Romania, and Spain, representing around 80% of the 432 million European Union (EU) adult population. In each country, a representative sample of around 1,000 subjects aged 15 years and older was interviewed, for a total of 11,902 participants.

RESULTS

Overall, 25.9% of participants were current smokers (31.0% of men and 21.2% of women, P < 0.001), while 16.5% were former smokers. Smoking prevalence ranged from 18.9% in Italy to 37.0% in Bulgaria. It decreased with increasing age (compared to <45, multivariable odds ratio [OR] for ≥65 year, 0.31; 95% confidence interval [CI], 0.27-0.36), level of education (OR for low vs high, 1.32; 95% CI, 1.17-1.48) and self-rated household economic level (OR for low vs high, 2.05; 95% CI, 1.74-2.42). The same patterns were found in both sexes.

CONCLUSIONS

These smoking prevalence estimates represent the most up-to-date evidence in Europe. From them, it can be derived that there are more than 112 million current smokers in the EU-28. Lower socio-economic status is a major determinant of smoking habit in both sexes.

Safety of a change in the conditions of use of galacto-oligosaccharides as a novel food ingredient in food supplements pursuant to Regulation (EU) 2015/2283

Following a request from the European Commission, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was asked to deliver an opinion on the change in the conditions of use of galacto-oligosaccharides (GOS) as a novel food (NF) pursuant to Regulation (EU) 2015/2283. The NF is mainly composed of GOS, consisting of different galactosyl residues (two to nine) linked to a terminal glucose by a β-glycosidic bond but also contains lactose and its monomers (galactose and glucose). The NF is a syrup containing ≥ 55% GOS (w/w dry matter) and is produced enzymatically by two β-galactosidases. GOS produced by β-galactosidases according to the same production process is already authorised and included in the EU Union list of novel foods. This application is limited to an assessment of the proposed increase of the use level as food supplement. The proposed change in the conditions of use increases the maximum level in food supplements from 0.333 kg GOS/kg food supplement (33.3%) to 0.450 kg GOS/kg food supplement (45.0%). Since it is recommended that individuals consume no more than 3 servings of 12 g/day, the maximum recommended daily intake would be no more than 16.2 g GOS. No new food uses or other increases to the already approved use levels are being proposed. The information provided on the proposed use levels and anticipated intake do not raise safety concerns. The Panel concludes that the proposed increase in the maximum level of galacto-oligosaccharides as a NF in food supplements is safe under the proposed changes in conditions of use.

Safety of lacto-N-neotetraose (LNnT) produced by derivative strains of E. coli BL21 as a novel food pursuant to Regulation (EU) 2015/2283

Following a request from the European Commission, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was asked to deliver an opinion on the change in the production process and specifications of lacto-N-neotetraose (LNnT) as a novel food (NF) pursuant to Regulation (EU) 2015/2283. The NF is mainly composed of the human-identical milk oligosaccharide (HiMO) LNnT but also contains lactose, lacto-N-triose II (LNT II), para-lacto-N-neo-hexaose (para-LNnH) and other related carbohydrates. The NF is produced by fermentation with two genetically modified strains of Escherichia coli BL21. LNnT when chemically synthesised or produced by microbial fermentation using another E. coli strain (K-12) is already authorised and included in the EU list of NFs. This application is limited to a change in the manufacturing process and specifications while target population, uses and use levels and consequently the anticipated intake do not change. The information provided on the manufacturing process, including the absence of DNA from the producing microorganisms, composition, identity and specifications of the NF do not raise safety concerns. Particularly, the proposed changes in the specifications are limited to a slightly higher ash content and limits for the presence of yeast and moulds, while specifications for methanol and LNnT fructose isomer have been removed. Food supplements are not intended to be used if other foods with the added NF or breast milk for young children are consumed on the same day. The Panel concludes that lacto-N-neotetraose (LNnT) as a NF when produced by fermentation with two genetically modified strains of E. coli BL21 is safe under the proposed conditions of use.

Late inflow or outflow obstruction requiring surgical intervention after HeartMate 3 left ventricular assist device insertion

Inflow or outflow obstruction is a rare, but critical complication after HeartMate 3 left ventricular assist device implantation. We retrospectively reviewed 166 patients who underwent primary HeartMate 3 implantation at our centre between November 2014 and July 2019. Three cases of inflow obstruction and 3 cases of outflow obstruction were identified. Presence of low flow alarm was the most common presenting sign and they were free from heart failure symptoms except in 1 case. They all underwent surgical correction and the median time from primary implantation to reintervention was 406.5 days. Computed tomography angiogram identified a problem in 5 out of 6 cases. Clinical symptoms and/or alarms resolved after surgery, but 1 case developed recurrent low flow alarm due to partial occlusion of inflow by fibrous tissue who eventually underwent heart transplant. All patients remain alive with median follow-up of 433.5 days. Prompt surgical intervention in late inflow and outflow obstruction after HeartMate 3 implantation resulted in favourable outcomes.