Selection and treatment of candidates for heart transplantation. A statement for health professionals from the Committee on Heart Failure and Cardiac Transplantation of the Council on Clinical Cardiology, American Heart Association

A second chance for a new heart? The role of metabolic and bariatric surgery in patients with end-stage heart failure

BACKGROUND

Obesity is an independent risk factor for heart failure (HF). Substantial weight loss has been shown to reverse obesity-related cardiomyopathy. This study aimed to report our institution's experience with laparoscopic sleeve gastrectomy (LSG) in patients with morbid obesity and end-stage HF.

METHODS

Between 2018 and 2022, 26 patients with end-stage HF were referred for LSG. Of 26 patients, 16 underwent an operation, and 10 did not. After institutional review board approval, a retrospective electronic medical record review was performed to evaluate (i) age, (ii) preoperative weight, (iii) decrease in body mass index (BMI) score, (iv) whether the patient underwent heart transplantation, and (v) mortality. Data analysis was performed using Stata/SE (version 17.0; StataCorp). The Wilcoxon rank-sum test was used to compare continuous variables between the cohorts, and the Pearson chi-square test was used for binary variables with Bonferroni correction applied.

RESULTS

The LSG and non-LSG cohorts had comparable ages (P = .088) and starting BMI score (P = .918), and a proportion of patients had a ventricular assist device (P = .191). Patients who underwent LSG lost significantly more weight than the patients who did not, with an average decrease in BMI score of 8.9 kg/m2 (SD, ±6.13) and 1.1 kg/m2 (SD, ±4.10), respectively (P = .040). Of note, 6 patients (37.5%) who underwent LSG eventually underwent transplantation, compared with 2 patients (20.0%) from the matched cohort (P = .884). Of the 26 patients, there were 6 deaths: 2 (12.5%) in the LSG cohort and 4 (40.0%) in the non-LSG cohort (P = .525).

CONCLUSION

LSG may be safe and effective for weight loss in patients with HF. This operation may provide patients affected by obesity with end-stage HF the lifesaving opportunity to achieve transplant candidacy.

Exercise Rehabilitation for People With End-Stage Kidney Disease: Who Will Fill the Gaps?

Exercise rehabilitation is a well established therapy for reducing morbidity and mortality and improving quality of life and function across chronic conditions. People with dialysis-dependent kidney failure have a high burden of comorbidity and symptoms, commonly characterised as fatigue, dyspnoea, and the inability to complete daily activities. Despite more than 30 years of exercise research in people with kidney disease and its established benefit in other chronic diseases, exercise programs are rare in kidney care and are not incorporated into routine management at any stage. In this review, we describe the mechanisms contributing to exercise intolerance in those with end-stage kidney disease and outline the role of exercise rehabilitation in addressing the major challenges to kidney care: cardiovascular disease, symptom burden, and physical frailty. We also draw on existing models of exercise rehabilitation from other chronic conditions to inform the way forward and challenge the status quo of exercise rehabilitation in both practice and research.

Prognostic value of 6-min walk test compared to cardiopulmonary exercise test in patients with severe heart failure

AIMS

The 6-min walk test (6MWT) and cardiopulmonary exercise test (CPET) are both predictive in heart failure (HFrEF). Although 6MWT substitutes for CPET in HFrEF patients, as submaximal testing may be preferable, its prognostic superiority still needs to be verified, particularly in regard to beta blockers (BBs). We aimed to compare the prognostic role of CPET and 6MWT and investigate whether BB therapy influences the predictive value.

METHODS

This is a single-center, retrospective study. Advanced HFrEF patients were followed up for 3 years: events were cardiovascular death or urgent heart transplantation. We analyzed the predictive capacity of CPET and 6MWT in patients, and subdivided according to use of BBs.

RESULTS

In a group of 251 HFrEF patients, we found a correlation between meters and peak VO2 (r2 = 0.94). Over the 3-year follow-up, 74 events were recorded. Both CPET and 6MWT variables were correlated with outcome at univariate analysis (meter and VE/VCO2 slope, peak VO2, VO2 at ventilatory anaerobic threshold, percentage predicted of peak VO2), but only percentage predicted of peak VO2 (pppVO2) was an independent predictor. In 103 HFrEF patients on BBs (23 nonsurvivors), neither pppVO2 nor meter were predictive, while in 148 patients not treated with BB (51 with events) pppVO2 was selected as an independent prognostic parameter (P = 0.001).

CONCLUSIONS

6MWT is a valid alternative to CPET, although the percentage of predicted of peak VO2 emerged as the strongest predictor. Nonetheless, our results suggest that both functional derived parameters are not predictive among those patients treated with BBs. Further studies are necessary to confirm these findings.

Outcomes of diabetic patients with end-stage heart failure listed for heart transplantation: A propensity-matched analysis

BACKGROUND

We investigated the current trends and outcomes of diabetic patients listed for heart transplants in the U.S. and provided a method for risk-stratification.

METHODS

Using data from the United Network for Organ Sharing (UNOS), we identified heart failure patients listed for heart transplants between 2010 and 2019. Diabetic patients were propensity-matched with non-diabetics, and waitlist mortality as well as post-transplant graft survival were compared between the two groups. Further risk-stratification of diabetic patients was done based on the risk factors that independently predict graft failure.

RESULTS

28,928 adult patients (30% diabetic) with end-stage heart failure were added to the waitlist over the study period. In the propensity-matched cohort, waitlist mortality was higher in diabetic patients compared to non-diabetics (HR = 1.13 (95% CI = 1.04-1.22, p = 0.002). Over the study period, 5739 patients with diabetes were transplanted. In the propensity-matched cohorts of transplant recipients, the rate of graft failure was significantly higher for diabetic patients (23.3%) compared to non-diabetics (20.4%); HR = 1.17, 95% CI = 1.08-1.26, p<0.001. We identified 12 risk factors of graft failure among diabetic patients and developed a risk score that further risk-stratify these patients. Diabetic patients at low risk (score≤4) had similar graft survival as patients without diabetes (HR = 0.91, 95% CI = 0.82-1.01, p = 0.06). On the other hand, high-risk diabetic patients had worse graft survival compared to non-diabetics (HR = 1.52, 95% CI = 1.38-1.67, P<0.001).

CONCLUSION

Among patients with end-stage heart failure, pre-existing diabetes was associated with higher waitlist mortality and worse graft survival. However, with careful patient selection, graft survival is similar to those without diabetes. This article is protected by copyright. All rights reserved.

Oxygen Delivery Approaches to Augment Cell Survival After Myocardial Infarction: Progress and Challenges

Myocardial infarction (MI), triggered by blockage of a coronary artery, remains the most common cause of death worldwide. After MI, the capability of providing sufficient blood and oxygen significantly decreases in the heart. This event leads to depletion of oxygen from cardiac tissue and consequently leads to massive cardiac cell death due to hypoxemia. Over the past few decades, many studies have been carried out to discover acceptable approaches to treat MI. However, very few have addressed the crucial role of efficient oxygen delivery to the injured heart. Thus, various strategies were developed to increase the delivery of oxygen to cardiac tissue and improve its function. Here, we have given an overall discussion of the oxygen delivery mechanisms and how the current technologies are employed to treat patients suffering from MI, including a comprehensive view on three major technical approaches such as oxygen therapy, hemoglobin-based oxygen carriers (HBOCs), and oxygen-releasing biomaterials (ORBs). Although oxygen therapy and HBOCs have shown promising results in several animal and clinical studies, they still have a few drawbacks which limit their effectiveness. More recent studies have investigated the efficacy of ORBs which may play a key role in the future of oxygenation of cardiac tissue. In addition, a summary of conducted studies under each approach and the remaining challenges of these methods are discussed.

Ocular perfusion in patients with reduced left ventricular ejection fraction measured by optical coherence tomography angiography

AIMS

The aim of this study is to evaluate retinal and optic nerve head (ONH) perfusion in patients with systolic chronic heart failure (CHF) compared to healthy control subjects.

METHODS

Twenty-seven eyes of 27 patients with CHF (study group) and 31 eyes of 31 healthy subjects (control group) were prospectively included in this study. CHF Patients had a left ventricular ejection fraction (LVEF) < 50% and were classified by New York Heart Association (NYHA) class. OCT-A was performed using RTVue XR Avanti with AngioVue (Optovue, Inc, Fremont, CA, USA). The area of the foveal avascular zone (FAZ) and flow density (FD) data were extracted and analyzed.

RESULTS

There was no significant difference in the signal strength index between the study group (group 1) and the control group (group 2) (ONH: p = 0.015; macula: p = 0.703). The difference in the area of the foveal avascular zone between the two groups was also not significant (p = 0.726). The flow density (whole en face) in the ONH (RPC) in group 1 was significantly lower compared to control (group 1 = 48.40 ± 2.48 (49.0 [46.7, 50.3]); group 2 = 50.15 ± 1.85 (50.6 [48.5, 51.70]); p = 0.008). There was a significant and strong correlation between LVEF and the macular flow density (whole en face) (superficial: rs = 0.605 deep: rs = 0.425, p < 0.01).

CONCLUSIONS

Patients with CHF showed reduced flow density compared with healthy controls. The reduced FD correlated with the LVEF and the functional (NYHA) class. Retinal perfusion as measured using OCTA might provide an insight into the global microperfusion and hemodynamic state of heart failure patients.

Long-Term Clinical and Hemodynamic Outcomes after Heart Transplantation in Patients Pre-Treated with Sildenafil

BACKGROUND

Elevated pulmonary vascular resistance remains a major problem for heart transplant (HT) candidate selection.

OBJECTIVE

This study sought at assess the effect of pre-HT sildenafil administration in patients with fixed pulmonary hypertension.

METHODS

This retrospective, single-center study included 300 consecutive, HT candidates treated between 2003 and 2013, in which 95 patients had fixed PH, and of these, 30 patients were treated with sildenafil and eventually received a transplant, forming Group A. Group B included 205 patients without PH who underwent HT. Pulmonary hemodynamics were evaluated before HT, as well as 1 week after and 1 year after HT. Survival was compared between the groups. In this study, a p value < 0.05 was considered statistically significant.

RESULTS

After treatment with sildenafil but before HT, PVR (-39%) and sPAP (-10%) decreased significantly. sPAP decreased after HT in both groups, but it remained significantly higher in group A vs. group B (40.3 ± 8.0 mmHg vs 36.5 ± 11.5 mmHg, p=0.022). One year after HT, sPAP was 32.4 ± 6.3 mmHg in group A vs 30.5 ± 8.2 mmHg in group B (p=0.274). The survival rate after HT at 30 days (97% in group A versus 96% in group B), at 6 months (87% versus 93%) and at one year (80% vs 91%) were not statistically significant (Log-rank p=0.063). After this first year, the attrition rate was similar among both groups (conditional survival after 1 year, Log-rank p=0.321).

CONCLUSION

In patients with severe PH pre-treated with sildenafil, early post-operative hemodynamics and prognosis are numerically worse than in patients without PH, but after 1 year, the medium to long-term mortality proved to be similar. (Arq Bras Cardiol. 2021; 116(2):219-226).

Comparison among different multiparametric scores for risk stratification in heart failure patients with reduced ejection fraction

Heart failure is a serious condition with high prevalence (about 2% in the adult population in developed countries, and more than 8% in patients older than 75 years). About 3–5% of hospital admissions are linked with heart failure incidents. The guidelines of the European Society of Cardiology for the diagnosis and treatment of acute and chronic heart failure have identified individual markers in patients with heart failure, including demographic data, aetiology, comorbidities, clinical, radiological, haemodynamic, echocardiographic and biochemical parameters. Several scoring systems have been proposed to identify adverse events, such as destabilizations, re-hospitalizations and mortality. This article reviews scoring systems for heart failure prognostication, with particular mention of those models with exercise tolerance objective definition. Although most of the models include readily available clinical information, quite a few of them comprise circulating levels of natriuretic peptides and a more objective evaluation of exercise tolerance. A literature review was also conducted to (a) identify heart failure risk-prediction models, (b) assess statistical approach, and (c) identify common variables.

Aetiology and 30-Year Long-Term Outcome of Children with Cardiomyopathy Necessitating Heart Transplantation

Studies assessing the long-term outcome after heart transplantation HTX in patients with cardiomyopathy (CM) in the paediatric age range are rare. The aim of this study was to determine the survival rate of children with CM undergoing HTX and to analyse how aetiology of cardiomyopathy influenced morbidity and mortality. We retrospectively analysed the medical records of children; who were transplanted in our centre between June 1988 and October 2019. 236 heart transplantations were performed since 1988 (9 re-transplants). 98 of 227 patients (43.2%) were transplanted because of CM. Survival rates were 93% after 1; 84% after 10 and 75% after 30 years. Overall; the aetiology of CM could be clearly identified in 37 subjects (37.7%). This rate increased up to 66.6% (12/19) by applying a comprehensive diagnostic workup since 2016. The survival rate was lower (p < 0.05) and neurocognitive deficits were more frequent (p = 0.001) in subjects with systemic diseases than in individuals with cardiac-specific conditions. These data indicate that the long-term survival rate of children with CM after HTX in experienced centers is high. A comprehensive diagnostic workup allows unraveling the basic defect in the majority of patients with CM undergoing HTX. Aetiology of CM affects morbidity and mortality in subjects necessitating HTX.

Heart transplantation in patients with localized prostate cancer-Are we denying a life-saving therapy due to an indolent tumor?

BACKGROUND

Prostate cancer (PC) is the most common non-cutaneous cancer in men. Approximately 90% of these cancers are localized (LPC) with a cancer-specific survival rate of 99% at 10 years. Some heart transplant centers (HTCs) regard PC as an absolute contraindication to heart transplantation (HT). This study aims to understand the current status of HT in patients with advanced heart failure (AHF) and concurrent LPC in the United States.

METHODS

Adult HTCs in the United States were asked to fill out an email questionnaire addressing their current approach to HT in AHF patients with concurrent LPC.

RESULTS

Fifty of the 90 HTCs that received the questionnaire responded. Only 16% of HTCs had a formal policy regarding HT in patients with LPC, while only 10% had patients with LPC on the HT waitlist at the time of the survey. Overall, 84% of the HTCs had never performed HT in a patient with LPC in the history of their transplant program.

CONCLUSION

An overwhelming majority of HTCs in the United States do not consider HT an option for AHF patients with concurrent LPC and lack a formal policy regarding the same.

Very high levels of PSA in patients with cardiogenic shock: Report of four clinical cases

Prostate-specific antigen (PSA) is the tumor marker most widely used in conjunction with digital rectal examination (DRE) for the early detection of prostate cancer (PCa). Due to its limitations, especially the high rate of false positive (FP) results, PSA screening of transplant candidates is a controversial issue. Moreover, obtaining a FP result in the PCa screening of heart transplant candidates may lead to potentially harmful effects. Although most of the factors that may cause PSA FP results are well known, FP results related to cardiogenic shock, a common indication for heart transplant, are less known. We studied retrospectively four patients who suffered cardiogenic shock during their hospital stay and became heart transplant candidates. Their PSA serum levels were very high suggesting the presence of PCa. Our findings have shown that elevated PSA serum levels in these patients were not related to PCa and they might be associated with cardiogenic shock. This clinical case study adds evidences to the fact that cardiogenic shock is an important cause of PSA FP results, therefore it cannot be used as a reliable marker of PCa in this clinical condition and positive results should be properly interpreted.

FibroSURE and elastography poorly predict the severity of liver fibrosis in Fontan-associated liver disease

OBJECTIVE

As the population of patients with Fontan circulation surviving into adulthood increases, hepatic cirrhosis has grown to be a significant cause of morbidity and mortality. Early detection of advanced hepatic fibrosis is imperative for proper intervention and consideration for heart or combined heart/liver transplantation. Noninvasive biomarkers and elastography have been evaluated for their diagnostic utility with variable results in the Fontan population.

DESIGN

The cohort included 14 patients age 26.4 SD 7.5 who underwent Fontan surgery. All patients were evaluated with FibroSURE, shear wave elastography (SWE), hepatic duplex sonography, and liver biopsy. Liver fibrosis on biopsy was evaluated according to the congestive hepatic fibrosis system.

RESULTS

In our cohort, 100% of patients had fibrosis with 36% demonstrating advanced fibrosis. FibroSURE agreed with liver biopsy in only 5 out of 14 cases (36%): underestimating in 7 and overestimating in 2 individuals. SWE agreed with liver biopsy in 0% of cases: overestimating in 10 and underestimating in 4 cases. None of the duplex sonography indices predicted the presence or severity of liver fibrosis.

CONCLUSION

This study demonstrates that children who have undergone a Fontan procedure universally develop some hepatic fibrosis and a significant number have advanced fibrosis by adulthood. The FibroSURE blood test, SWE, and hepatic duplex sonography were unable to accurately predict the presence or severity of hepatic fibrosis when compared with liver biopsy. Further studies are needed to investigate novel noninvasive methods and/or biomarkers that can adequately detect advanced hepatic fibrosis before the development of cirrhosis and hepatic decompensation.

Noninvasive Echocardiographic Measures of Pulmonary Vascular Resistance in Children and Young Adults with Cardiomyopathy

BACKGROUND

Patients with cardiomyopathy (CM) are at increased risk for pulmonary hypertension (PH). Data are lacking on the use of noninvasive PH measures by echocardiography in patients with CM. The aim of this study was to evaluate the correlation between Doppler-derived echocardiographic indices and catheterization-based measurement of pulmonary vascular resistance (PVR) in children and young adults with CM.

METHODS

Imaging studies were retrospectively reviewed from pediatric patients with CM who underwent both echocardiography and cardiac catheterization within a 72-hour period. The ratio of peak tricuspid regurgitation velocity to right ventricular outflow tract velocity-time integral, the S/D ratio, and right ventricular myocardial performance index were correlated with invasive PVR. Receiver operating characteristic curves were developed to determine cutoffs for detecting PVR ≥ 6 indexed Wood units, a value associated with higher heart transplantation risk.

RESULTS

Twenty-three patients with CM (median age, 11.7 years; range, 0.5-21 years) met the criteria for analysis, the majority (n = 17 [74%]) of whom had dilated CM. Linear regression showed significant correlations between echocardiography-based ratio of peak tricuspid regurgitation velocity to right ventricular outflow tract velocity-time integral, S/D ratio, and right ventricular myocardial performance index versus invasive PVR (r = 0.84, r = 0.72, and r = 0.72, respectively, P < .001). All echocardiographic measures showed high sensitivity, specificity, and predictive values to detect PVR ≥ 6 indexed Wood units, with ratio of peak tricuspid regurgitation velocity to right ventricular outflow tract velocity-time integral demonstrating the highest area under the curve (0.958; 95% CI, 0.866-1).

CONCLUSIONS

Right-sided Doppler-derived echocardiographic indices correlate with PVR measured by cardiac catheterization in children and young adults with CM. These parameters may serve as useful adjuncts in serial assessment of right ventricular hemodynamics in this population.

A New Method of Mechanical Circulatory Support with an Implantable Multichamber Pump System (IMPS): Presentation and First Experimental Results

This paper presents a new cardiac support device for left ventricular failure which consists of two inflatable bellows positioned dorsally and ventrally to the left ventricle. The implantable multichamber pump system (IMPS) is driven by a pneumatic pump system and controlled by a microcomputer using ECG-trigger and pacemaker modules. It was implanted via thoracotomy in 8 pigs. The circulatory parameters were measured in the animals on β-blockers, with cardiac failure and in ventricular fibrillation with an activated (IMPS on) and deactivated (IMPS off) system.

IMPS significantly increased the left ventricular pressure (LVPsys IMPS off: 63 ∓ 6 mmHg vs IMPS on: 96 ∓ 8 mmHg) and the blood pressure in the common carotid artery (Bpca' IMPS off: 69/38 mmHg vs IMPS on: 95/40 mmHg).

The IMPS proved to be highly efficient in the therapy of animals with acute cardiac failure and in ventricular fibrillation in the experimental model. Apart from its efficiency the advantages with this system are the ease of handling and its high biocompatibility due to the lack of contact with circulating blood.

Treatment and Prognosis of Pulmonary Hypertension in the Left Ventricular Assist Device Patient

This review will discuss the medical management of pulmonary hypertension in patients with left ventricular assist devices. Although much has been written on the management of primary pulmonary hypertension, also called pulmonary arterial hypertension, this review will instead focus on the treatment of pulmonary hypertension secondary to left heart disease. The relevant pharmacotherapy can be divided into medications for treating heart failure, such as diuretics and β-blockers, and medications for treating pulmonary hypertension. We also discuss important preoperative considerations in patients with pulmonary hypertension; the relationships between left ventricular assist devices, pulmonary hemodynamics, and right heart failure; as well as optimal perioperative and long-term postoperative medical management of pulmonary hypertension.

Cancer evaluation in the assessment of solid organ transplant candidates: A systematic review of clinical practice guidelines

BACKGROUND

Active malignancies are a contraindication to transplantation, as immunosuppression can lead to worse cancer outcomes; therefore, ensuring transplant candidates are free of malignancy before transplantation is essential. This systematic review assesses the availability, quality, and consistency of recommended cancer evaluation prior to transplantation in Clinical Practice Guidelines (CPGs) for the selection of solid organ transplant candidates.

METHODS

We systematically searched for CPGs for the assessment of transplant candidates. The characteristics of included CPGs, strength of recommendations and supporting evidence were extracted. A quality assessment of the CPGs was conducted using the AGREE II tool.

RESULTS

We identified 52 CPG for the selection of solid organ transplant candidates. Only 13 (25%) included recommendations for cancer evaluation as part of the assessment of transplant candidates. Most recommended age and sex appropriate cancer screening as per the general population guidelines. Recommendations to evaluate for other malignancies and for high-risk candidates were variable. Most recommendations were based on expert opinion and only two CPGs provided an explicit link between the recommendations and supporting evidence.

CONCLUSION

There is a lack of clear and consistent recommendations for pretransplant cancer evaluation in existing CPGs. Although there is some consensus regarding the indication to screen for cancer as per the recommendations for the general population, these recommendations are not an appropriate risk reduction strategy for transplant candidates. Standardized protocols to ensure transplant candidates are cancer free prior to transplantation are needed.

Safety of renal transplantation in patients with bipolar or psychotic disorders: a retrospective study

Solid organ transplantation societies recommend a relative contraindication of transplantation for people with bipolar or psychotic disorders. Very few data are available on the outcome of kidney transplantation and the increased risk of kidney disease in those patients. We conducted a retrospective multicenter cohort study (1979-2014) including kidney allograft recipients with either bipolar (BD) or psychotic disorders prior to transplant. Objectives were kidney allograft and patient outcomes compared to a matched control group without psychiatric disorders and the evolution of psychiatric disorder at 60 months after transplantation. Forty-seven patients including 25 women were identified, 34 with BD and 13 with psychotic disorder. Patients' overall cumulative death rates at 60 months were not significantly different in both groups [12.2%; 95% confidence interval: (4.5-24.1) in the group with psychiatric disorder versus 5.2%; (1.7-11.7) in control group P = 0.11] as for cumulative allograft loss rates [11.7% (3.5-25.2) vs. 9.4% (4.4-16.8) in control group (P = 0.91)]. Twenty-three patients (16 with BD and seven with psychotic disorder) experienced at least one psychiatric relapse [incidence rate: 1.8/100 persons- months; 95% CI; (1.2-2.7)] totaling 13 hospitalizations within 60 months of follow-up. Four patients stopped immunosuppressive therapy leading to allograft loss in three. Our study suggests that patients with BD or psychotic disorders have to be considered for renal transplantation with close psychiatric follow-up after transplant.

New-Onset Diabetes Mellitus After Heart Transplantation - Incidence, Risk Factors and Impact on Clinical Outcome

BACKGROUND

New-onset diabetes mellitus (DM) can occur as a serious complication after heart transplantation, but the comparative data on its clinical impact on survival and on transplant-related adverse events are limited.Methods and Results:We reviewed a total of consecutive 391 patients aged ≥17 years undergoing isolated orthotopic heart transplantation at the present institution from 1992 to 2013. The entire cohort was divided into 3 groups: (1) no diabetes (n=257); (2) pre-existing DM (n=46); and (3) new-onset DM (n=88). Early and long-term clinical outcomes were compared across the 3 groups. Early death occurred in 8 patients (2.0%). Of the 345 non-diabetic patients before transplantation, 88 (25.5%) developed new-onset DM postoperatively. During follow-up, 83 (21.2%) died. On time-varying Cox analysis, new-onset DM was associated with increased risk for overall death (HR, 2.11; 95% CI: 1.26-3.55) and tended to have a greater risk for severe chronic kidney disease (HR, 1.77; 95% CI: 0.94-3.44). Compared with the no-diabetes group, the new-onset DM group had a worse survival rate (P=0.035), but a similar survival rate to that of the pre-existing DM group (P=0.364).

CONCLUSIONS

New-onset DM has a negative effect on long-term survival and kidney function after heart transplantation. Further studies are warranted to evaluate the relevance of early diagnosis and timely control of new-onset DM to improve long-term survival.

Statement on cardiopulmonary exercise testing in chronic heart failure due to left ventricular dysfunction: recommendations for performance and interpretation Part III: Interpretation of cardiopulmonary exercise testing in chronic heart failure and future applications: Task Force of the Italian Working Group on Cardiac Rehabilitation and Prevention (Gruppo Italiano di Cardiologia Riabilitativa e Prevenzione, GICR), endorsed by Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology

Optimal use of cardiopulmonary exercise testing (CPET) in clinical practice and chronic heart failure (CHF) requires appropriate data presentation and a flexible interpretative strategy. The greatest potential impact on the decision-making process may rest not on the value of any individual measurement, although some are obviously more important than others, but rather on their integrative use. Such an integrative approach relies on interrelationship, trending phenomena and patterns of key gas exchange variable responses. An multiparametric approach will be discussed in different clinical applications, for exercise prescription and monitoring, functional evaluation of drug therapy or cardiac resynchronisation therapy efficacy, and risk stratification. The role of CPET in the daily clinical decision-making process will be underscored. Future indications of CPET will be addressed, suggesting and promoting an extended candidacy either to all CHF patients, including those at high risk or most vulnerable, such as female, elderly patients, and patients with implantable cardioverter defibrillator or in every clinical setting where objective definition of exercise capacity provides implications for medical, surgical, and social decision making.

Oxygen cycling to improve survival of stem cells for myocardial repair: A review

Heart disease represents the leading cause of death among Americans. There is currently no clinical treatment to regenerate viable myocardium following myocardial infarction, and patients may suffer progressive deterioration and decreased myocardial function from the effects of remodeling of the necrotic myocardium. New therapeutic strategies hold promise for patients who suffer from ischemic heart disease by directly addressing the restoration of functional myocardium following death of cardiomyocytes. Therapeutic stem cell transplantation has shown modest benefit in clinical human trials with decreased fibrosis and increased functional myocardium. Moreover, autologous transplantation holds the potential to implement these therapies while avoiding the immunomodulation concerns of heart transplantation. Despite these benefits, stem cell therapy has been characterized by poor survival and low engraftment of injected stem cells. The hypoxic tissue environment of the ischemic/infracting myocardium impedes stem cell survival and engraftment in myocardial tissue. Hypoxic preconditioning has been suggested as a viable strategy to increase hypoxic tolerance of stem cells. A number of in vivo and in vitro studies have demonstrated improved stem cell viability by altering stem cell secretion of protein signals and up-regulation of numerous paracrine signaling pathways that affect inflammatory, survival, and angiogenic signaling pathways. This review will discuss both the mechanisms of hypoxic preconditioning as well as the effects of hypoxic preconditioning in different cell and animal models, examining the pitfalls in current research and the next steps into potentially implementing this methodology in clinical research trials.

Right heart catheterisation may be cautiously performed through a mechanical valve prosthesis in the tricuspid position

Right heart catheterisation (RHC) may be performed through a mechanical valve prosthesis in the tricuspid position using a partially inflated pulmonary artery flotation catheter. Preprocedural preparation should include an ex vivo trial with an identical valve prosthesis and the type of catheter to be used for the procedure. The operator should expect immediate unloading of the right ventricle due to catheter-associated tricuspid regurgitation, but it is possible to estimate pulmonary vascular resistance using the Fick principle. The risk of catheter entrapment or damage to the prosthetic leaflets during the procedure is likely to be low. This risk may be acceptable to the clinician and the patient if pulmonary vascular resistance must be measured in order to determine eligibility for heart transplantation.

Carotid Artery Stenting in a Patient With a Continuous-Flow Left Ventricular Assist Device

PURPOSE

To demonstrate the safety and feasibility of carotid artery stenting (CAS) in a patient with a continuous-flow left ventricular assist device (LVAD).

CASE REPORT

A 54-year-old woman with a LVAD was referred for a 90% stenosis of the right internal carotid artery (ICA). The patient was offered CAS, and oral anticoagulant was not discontinued in the periprocedural period. Because of absent arterial pulses, percutaneous transfemoral access was obtained under ultrasound guidance. Particular attention was paid to cannulation of the innominate artery; a 7-F guiding catheter was advanced from the descending aorta into the innominate artery under road-mapping, avoiding maneuvers in the ascending aorta where the outflow Dacron graft of the LVAD was anastomosed. To avoid cerebral flow modifications, the Angioguard RX was used as the cerebral protection device rather than other devices such as the flow reversal or flow-clamping systems. At this point, CAS was performed in a standard fashion using the 7×30-mm Precise ProRX stent. The computed tomography angiogram at 6 months showed patency of the stented right ICA.

CONCLUSION

With adequate planning, CAS appears feasible in patients with a LVAD.

Peak oxygen uptake and self-reported physical health are strong predictors of long-term survival after heart transplantation

BACKGROUND

Peak oxygen uptake (VO2peak ) is known as the gold standard measure of cardiopulmonary fitness. We therefore hypothesized that measures of physical health would predict long-term survival in heart transplant recipients (HTx).

METHODS

This retrospective study investigated survival in two HTx populations; the cardiopulmonary exercise test (CPET) cohort comprised 178 HTx patients who completed a VO2peak test during their annual follow-up (1990-2003), and the SF-36 cohort comprised 133 patients who completed a quality of life questionnaire, SF-36v1 (1998-2000).

RESULTS

Mean (SD) age in the CPET cohort was 52 (12) yr and 54 (11) yr in the SF-36 cohort. Mean observation time was, respectively, 11 and 10 yr. Mean (SD) VO2peak was 19.6 (5.3) mL/kg/min, and median (IR) physical function (PF) score was 90 (30). VO2peak and PF scores were both significant predictors in univariate Cox regression. Multiple Cox regression analyses adjusted for other potential predictors showed that VO2peak , age, and cardiac allograft vasculopathy (CAV) were the most important predictors in the CPET cohort, whereas age, PF score, smoking, and CAV were the most important predictors in the SF-36 cohort. In Kaplan-Meier analysis, VO2peak and PF scores above the median value were related to significant longer survival time.

CONCLUSION

Peak oxygen uptake and self-reported physical health are strong predictors for long-term survival in HTx recipients. VO2peak is a crucial measurement and should be more frequently used after HTx.

Role of Vasodilator Testing in Pulmonary Hypertension

Pulmonary hypertension is clinically defined by a mean pulmonary artery (PA) pressure of 25mm Hg or more at rest, as measured by right heart catheterization. To identify patients who are likely to have a beneficial response to calcium channel blockers (CCBs) and therefore a better prognosis, acute vasodilator testing should be performed in patients in certain subsets of pulmonary arterial hypertension (PAH). A near normalization of pulmonary hemodynamics is needed before patients can be considered for therapy with CCBs. Intravenous adenosine, intravenous epoprostenol, inhaled nitric oxide, or inhaled iloprost are the standard agents used for vasoreactivity testing in patients with idiopathic PAH. In this review we describe the various aspects of vasodilator testing including the rationale, pathophysiology and agents used in the procedure.

The influence of illness severity on health satisfaction in patients with cardiovascular disease: the mediating role of illness perception and self-efficacy beliefs

The importance of psychological factors in improving conditions of cardiovascular disease (CVD) patients is stressed by the guidelines for their prevention and rehabilitation, but little is known about the impact of illness severity on patients' well-being, and on the psychosocial variables that may mediate this association. The aim of this study was to investigate the role of illness perception and self-efficacy beliefs on the relationship between illness severity and health satisfaction in 75 CVD patients undergoing rehabilitation (80% men; mean age = 65.44) at the St. Luca Hospital, Istituto Auxologico Italiano, Milan, Italy. Illness severity was measured in terms of left ventricular ejection fraction; psychological factors were assessed at the beginning and end of rehabilitation. Results from path analyses showed that the relationships among CVD severity and health satisfaction were mediated by illness perception and self-efficacy beliefs. Findings underscored the importance of considering illness representations and self-efficacy beliefs to improve well-being in CVD patients.

Levosimendan improves exercise performance in patients with advanced chronic heart failure

AIMS

Cardiopulmonary exercise test (CPET) provides parameters such as peak VO₂ and ventilation/CO₂ production (VE/VCO₂) slope, which are strong prognostic predictors in patients with stable advanced chronic heart failure (ADHF). The study aim was to evaluate the effects of the inodilator levosimendan on CPET in patients with ADHF under stable clinical conditions.

METHODS AND RESULTS

We enrolled patients with ADHF (peak VO₂ < 12 mL/min/kg) in a double-blind, placebo-controlled protocol. Patients were randomly assigned to i.v. infusion of placebo (500 mL 5% glucose; n = 19) or levosimendan (in 500 mL 5% glucose; n = 23). Before and 24 h after the end of the infusion, patients underwent determination of New York Heart Association class, B-type natriuretic peptide (BNP), haemoglobin, serum creatinine, and blood urea nitrogen levels, as well as CPET, standard spirometry, and alveolar capillary gas diffusion. BNP showed no change with placebo (1042 ± 811 to 1043 ± 867 pg/mL), but it was decreased with levosimendan (1163 ± 897 to 509 ± 543 pg/mL, P < 0.001). No changes were observed for haemoglobin, creatinine, and blood urea nitrogen in either group. With levosimendan, a minor improvement was observed in spirometry measurements, but not in alveolar capillary gas diffusion. Peak VO₂ showed a small, non-significant increase with placebo (9.5 ± 1.7 to 10.0 ± 2.1 mL/kg/min, P = 0.12), and a greater increase with levosimendan (9.8 ± 1.7 to 11.0 ± 1.9 mL/kg/min, P < 0.005). The VE/VCO₂ slope showed no change (44.0 ± 11 vs. 43.4 ± 10.3, P = 0.44), and a decrease (41.9 ± 10 vs. 36.6 ± 6.4, P < 0.001) in the placebo and in the levosimendan group, respectively.

CONCLUSION

Levosimendan treatment significantly improves peak VO₂ and reduces VE/VCO₂ slope and BNP in patients with ADHF.

The liver in heart failure: a biopsy and explant series of the histopathologic and laboratory findings with a particular focus on pre-cardiac transplant evaluation

The pathologic liver changes in chronic heart failure have been characterized mostly based on autopsy series and include sinusoidal dilation and congestion progressing to pericellular fibrosis, bridging fibrosis, and ultimately to cardiac cirrhosis or sclerosis. Liver biopsies are commonly obtained as part of the work up before heart transplantation in patients with longstanding right heart failure, particularly if ascites, abnormal liver function tests or abnormal abdominal imaging are noted as part of the pre-transplant evaluation. In these cases, the liver biopsy findings may be used to further risk stratify patients for isolated heart or combined heart and liver transplantation. Thus, it is important to be able to correlate the histologic changes with post-transplant outcomes. We report the pathologic and clinical findings in liver explants from six patients who underwent combined heart-liver transplantation. We also report preoperative liver biopsy findings from 21 patients who underwent heart transplantation without simultaneous liver transplantation. We staged the changes related to chronic passive congestion as follows: stage 0-no fibrosis; stage I-pericellular fibrosis; stage II-bridging fibrosis; and stage III-regenerative nodules. Nineteen biopsies showed fibrosis with bridging fibrosis in 13 and regenerative nodules in 6. Fifteen patients were alive at 1 year post transplant. Only three patients had a post-operative course that was characterized by signs and symptoms of chronic liver disease. Pre-transplant liver biopsies from these patients all showed at least stage II fibrosis. These patients survived for 3, 6, and 10 months after cardiac transplant. The presence of bridging fibrosis was not significantly associated with post-operative survival (P=0.336) or post-operative liver failure (P=0.257). We conclude that patients with bridging fibrosis may still be considered viable candidates for isolated heart transplantation. Because the pattern of fibrosis due to passive congestion is highly variable throughout the liver, a diagnosis of cirrhosis, which implies fibrosis and regenerative nodules throughout the liver, should be made with great caution on biopsy.

Heart and brain interconnection - clinical implications of changes in brain function during heart failure

Heart failure (HF) is a highly prevalent disorder worldwide and, consequently, a burden on the healthcare systems of many nations. Although the effects of HF are systemic, many therapeutic targets are focused on cardiac dysfunction. The brain is closely related to the heart, but there are few reports on the relationship between these organs. We describe the effects of the brain on HF progression. Specific brain regions control sympathetic drive and neurohumoral factors, which play an important role in disease exacerbation. In addition, we review some of our previous studies on deranged cerebral metabolism and reduced cerebral blood flow during HF. Although the reasons underlying these effects during HF remain uncertain, we propose plausible mechanisms for these phenomena. In addition, the clinical implications of such conditions in terms of predicting prognosis are discussed. Finally, we investigate cognitive impairment in patients with HF. Cognitive impairment through cerebral infarction or hypoperfusion is associated with adverse outcomes, including death. This brief review of brain function during the development of HF should assist with future strategies to better manage patients with this condition.

Case report of a patient with left ventricular assistance device undergoing chemotherapy for a new diagnosis of lung cancer

The optimal management of cancer in patients with severe heart failure is not defined. This issue is particularly challenging when a diagnosis of limited-stage small cell lung cancer (SCLC) is made incidentally in the context of evaluating patient for candidacy for cardiac transplantation. Limited-stage SCLC is typically managed on a curative therapeutic paradigm with combined modality approach involving chemotherapy and radiation. Even with excellent performance status and good organ function, the presence of severe cardiomyopathy poses significant challenges to the delivery of even single modality approach with chemotherapy or radiotherapy, let alone the typical curative combined modality approach. With mechanical left ventricular devices to provide cardiac support, treatment options for cancer in the setting of advanced heart failure may be improved. Here we discuss the therapeutic dilemma involving a patient with severe cardiomyopathy and left ventricular assistant device (LVAD) who was found to have limited-stage SCLC during the evaluation process for cardiac transplantation.

Pulmonary hypertension is associated with increased post-lung transplant mortality risk in patients with chronic obstructive pulmonary disease

BACKGROUND

Pulmonary hypertension associated with lung disease (PHLD) has been shown to be a predictor of disease severity and survival in patients awaiting lung transplantation. Little is known about the relationship of PHLD and survival after lung transplantation or how this may vary by disease. This study evaluated the effect of PHLD on 1-year survival after lung transplantation for patients with the 3 most common indications for transplantation: chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), and cystic fibrosis (CF).

METHODS

Organ Procurement and Transplantation Network data were obtained for all lung transplant recipients who received an allograft between May 2005 and June 2010. The relationship between PHLD and 1-year survival after lung transplantation for each diagnostic group was examined with Kaplan-Meier estimates and Cox regression. Covariates included in the model were those defined in the current Lung Allocation Score system post-transplant survival model, including age, serum creatinine, percentage predicted forced vital capacity, functional status, and mechanical ventilation use at time of transplant. The estimated relative risk was calculated using Poisson regression with robust error variance and adjustment for covariates.

RESULTS

Sample sizes for COPD, IPF, and CF patients were 2,025, 2,304, and 866, respectively. The 1-year post-transplant survival for COPD patients with PHLD was 76.9% vs 86.2% for COPD patients without PHLD (p = 0.001). In multivariate Cox regression analysis COPD patients with PHLD had a 1.74 (95% confidence interval, 1.3-2.3) times higher risk of 1-year post-transplant mortality (p = 0.001). Similar analyses for IPF and CF diagnostic groups showed no significant difference in survival between patients with and without PHLD.

CONCLUSIONS

COPD patients with PHLD have increased post-transplant 1-year mortality. No significant difference was seen in patients with IPF or CF. Further studies to evaluate the potential mechanisms for this difference between diagnoses are needed.

Inducing valvular regurgitation in mice via thermal ablation of cardiac valves

This study presents early data in the development of a novel mouse model of heart failure utilizing thermal ablation on cardiac valves to induce valvular regurgitation. Thermal ablation of the valve was achieved through the application of radiofrequency (RF) electrical current. The objective was to apply enough energy to induce valve stiffening and retraction, which was hypothesized to produce valve insufficiency and blood regurgitation in vivo. Preliminary studies were performed to develop a workable energy delivery catheter that could be inserted through the carotid artery to the aortic valve. Catheter position between the aortic valve leaflets was verified by echocardiography. Valve function was evaluated before and after the thermal insult using Doppler measurements near the valve inflow and outflow, and early results demonstrate that the energy delivery catheter could successfully induce acute valve insufficiency. Further study is needed to refine the catheter to provide greater control over the degree of thermal damage and resulting changes in cardiac physiology.

microRNA and Cardiac Regeneration

Heart diseases are a very common health problem in developed as well as developing countries. In particular, ischemic heart disease and heart failure represent a plague for the patients and for the society. Loss of cardiac tissue after myocardial infarction or dysfunctioning tissue in nonischemic cardiomyopathies may result in cardiac failure. Despite great advancements in the treatment of these diseases, there is a substantial unmet need for novel therapies, ideally addressing repair and regeneration of the damaged or lost myocardium. Along this line, cardiac cell based therapies have gained substantial attention. Three main approaches are currently under investigation: stem cell therapy with either embryonic or adult stem cells; generation of patient-specific induced pluripotent stem cells; stimulation of endogenous regeneration trough direct reprogramming of fibroblasts into cardiomyocytes, activation of resident cardiac stem cells or induction of native resident cardiomyocytes to reenter the cell cycle. All these strategies need to be optimized since their efficiency is low.It has recently become clear that cardiac signaling and transcriptional pathways are intimately intertwined with microRNA molecules which act as modulators of cardiac development, function, and disease. Moreover, miRNA also regulates stem cell differentiation. Here we describe how miRNA may circumvent hurdles that hamper the field of cardiac regeneration and stem cell therapy, and how miRNA may result as the most suitable solution for the damaged heart.

Left Ventricular Assist Device: Care On Inpatient Rehabilitation Facility

PURPOSE

Investigate the outcomes of patients admitted to an inpatient rehabilitation facility (IRF) after placement of a left ventricular assist device (LVAD).

DESIGN

Retrospective review of records.

METHOD

Authors reviewed records of patients admitted to the IRF after cardiac surgery or admission to the hospital with either acute myocardial infarction, congestive heart failure, or placement of an LVAD. The study reports improvement in function, length of stay (LOS), and location of discharge.

FINDINGS

The patients in the LVAD group made as much progress in terms of improvement in function as the other groups. None of the patients in the LVAD group required transfer back to medical or surgical units. All were discharged to home. Length of stay (LOS) of the LVAD group was not significantly longer than that of the other cardiac patients.

CONCLUSIONS

Patients who have had placement of an LVAD can be safely cared for in an IRF.

CLINICAL RELEVANCE

This paper provides information about the indications for LVAD, the nursing care of patients with an LVAD, and the outcomes of care in an IRF.

Congestive hepatic fibrosis score: a novel histologic assessment of clinical severity

Chronic right heart failure predisposes to hepatic passive congestion and centrizonal necrosis that may lead to hepatic fibrosis (cardiac sclerosis). Although there have been several studies on the histologic features of congestive hepatopathy, there is no available grading system. In this study we developed a novel grading system for congestive hepatic fibrosis. Liver biopsies were examined in patients with chronic heart failure of various etiologies including congenital heart disease, idiopathic cardiomyopathy, ischemic heart disease, and valvular heart disease. The cases with available echocardiography and/or right heart catheterization were included. Cases with other types of underlying chronic liver diseases, alcoholic liver disease, significant steatosis (>20%), malignant neoplasm, and acute heart failure or shock were excluded. After exclusion, 42 cases were included in the study. We herein proposed a novel congestive hepatic fibrosis score and correlated it with the right heart structure and function obtained by echocardiography and/or right heart catheterization. Our results showed that congestive hepatic fibrosis score is well correlated with the right atrial pressure (P for trend <0.001). The presence of portal fibrosis (congestive hepatic fibrosis scores 2 and 3) is associated with significantly higher right atrial pressure than those with no fibrosis (P<0.001) or with centrizonal fibrosis only (P=0.02). Congestive hepatic fibrosis score is also significantly associated with increasing severity of right atrial dilatation (P=0.03) and right ventricular dilatation (P=0.02), indicators for chronic volume and/or pressure overload. Other histopathologic features include sinusoidal dilatation and centrizonal hepatocyte atrophy. In summary, although sinusoidal dilatation and centrizonal fibrosis are the hallmarks of hepatic passive congestion, the presence of portal fibrosis is suggestive of more advanced disease, as it correlates with more severe impairment of right heart function, regardless of the etiologies of right heart failure. Congestive hepatic fibrosis score is a useful indicator of clinical severity.

Pediatric heart transplantation-indications and outcomes in the current era

Pediatric heart transplantation (HTx) remains an important treatment option in the care of children with end-stage heart disease, whether it is secondary to cardiomyopathy or congenital heart disease (CHD). As surgical outcomes for CHD have improved, the indications for pediatric HTx have had to be dynamic, not only for children with CHD but also for the growing population of adults with CHD. As the field of pediatric HTx has evolved, the outcomes for children undergoing HTx have improved. This is undoubtedly due to the continued research efforts of both single-center studies, as well as research collaboratives such as the International Society for Heart and Lung Transplantation (ISHLT) and the Pediatric Heart Transplant Study (PHTS) group. Research collaboratives are increasingly important in pediatric HTx as single center studies for a limited patient population may not elicit strong enough evidence for practice evolution. Similarly, complications that limit the long term graft survival may occur in a minority of patients thus pooled experience is essential. This review focuses on the indications and outcomes for pediatric HTx, with a special emphasis on studies generated by these research collaboratives.

Pediatric heart transplantation-indications and outcomes in the current era

Pediatric heart transplantation (HTx) remains an important treatment option in the care of children with end-stage heart disease, whether it is secondary to cardiomyopathy or congenital heart disease (CHD). As surgical outcomes for CHD have improved, the indications for pediatric HTx have had to be dynamic, not only for children with CHD but also for the growing population of adults with CHD. As the field of pediatric HTx has evolved, the outcomes for children undergoing HTx have improved. This is undoubtedly due to the continued research efforts of both single-center studies, as well as research collaboratives such as the International Society for Heart and Lung Transplantation (ISHLT) and the Pediatric Heart Transplant Study (PHTS) group. Research collaboratives are increasingly important in pediatric HTx as single center studies for a limited patient population may not elicit strong enough evidence for practice evolution. Similarly, complications that limit the long term graft survival may occur in a minority of patients thus pooled experience is essential. This review focuses on the indications and outcomes for pediatric HTx, with a special emphasis on studies generated by these research collaboratives.

Cardiopulmonary responses to exercise and its utility in patients with aortic stenosis

Utility of cardiopulmonary exercise test is unknown in patients with aortic stenosis. In this retrospective study, we examined the maximal indexes of cardiopulmonary testing at peak exercise in 155 consecutive patients with aortic valve area of ≤ 1.5 cm(2) who were referred for this test. The patients were passively followed up to assess their effect on the primary end point of all-cause mortality. We found that the absolute peak oxygen consumption (VO2) was significantly reduced in these patients, with age and gender-predicted peak VO2 of 80 ± 23%. Peak VO2 was markedly reduced (<80% of predicted) in 54% of patients. During a follow-up of 5 ± 4 years, a total of 41 patients died, and 72 underwent aortic valve replacement. Survival was significantly better in patients with higher absolute peak VO2 (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.80 to 0.93, p <0.001) and higher oxygen pulse (HR 0.80, 95% CI 0.74 to 0.9, p <0.001). In 83 patients who did not undergo valve replacement, higher peak VO2 and oxygen pulse were associated with better survival (HR 0.83, 95% CI 0.71 to 0.97, p = 0.024 and HR 0.80, 95% CI 0.66 to 0.96, p = 0.02, respectively). In conclusion, the peak VO2 is significantly reduced in patients with aortic stenosis. Higher peak VO2 is independently associated with better survival in these patients irrespective of whether they undergo valve replacement.