Recovery of Serum Cholesterol Predicts Survival After Left Ventricular Assist Device Implantation

The Lure of Cardiac Metabolism in the Diagnosis, Prevention, and Treatment of Heart Failure

Energy substrate metabolism and contractile function are tightly coupled in the heart. Within this framework, heart failure may be viewed as a state of impaired energy transfer. The metabolic changes in the failing heart are linked to functional and structural changes. A worthwhile goal is to measure metabolic flux and its regulation quantitatively, and to do this in a manner that leads to targeted interventions. For several good reasons, this goal has been elusive until now. The development of new analytical and imaging techniques offers the potential of exploring the landscape of metabolic changes across the different stages of heart failure. In this Review Topic of the Month, we focus on concepts and brevity to provide a strategic overview of cardiac metabolism in the diagnosis, prevention, and treatment of nonischemic heart failure.

Controlling Nutritional Status Score As a Predictive Marker for Patients With Implantable Left Ventricular Assist Device

Although a correlation between the nutritional status and the prognosis of patients with heart failure has been suggested, a correlation between the nutritional status and outcomes after the left ventricular assist device (LVAD) implantation remains unclear. We aimed to investigate the efficacy of the Controlling Nutritional Status (CONUT) score (range 0-12, including serum albumin, total cholesterol, and lymphocytes) as a nutritional index in speculating the prognosis of patients undergoing LVAD implantation. We examined 63 consecutive patients who underwent the continuous-flow LVAD implantation. Using the preoperative CONUT score, patients were categorized into two groups: lower CONUT score (0-4: normal to mild malnutrition) and higher CONUT score (5-12: moderate to severe malnutrition). We compared for the backgrounds and the clinical events after LVAD implantation. The higher CONUT group exhibited a significantly higher mean right atrial pressure (10.9 ± 4.7 vs. 7.3 ± 4.1 mmHg; p = 0.0019). In that group, the mortality rate was significantly higher (25% vs. 2.6%; p = 0.0059) and the Kaplan-Meier analysis showed lower survival rate. Furthermore, more bleeding events significantly occurred in the higher CONUT group. The preoperative CONUT score may reflect systemic venous congestion and offer a useful prognostic index of clinical courses after LVAD implantation.

A Population-Based Study of Early Postoperative Outcomes in Patients with Heart Failure Undergoing Bariatric Surgery

BACKGROUND

Weight loss following bariatric surgery can improve cardiac function among patients with heart failure (HF). However, perioperative morbidity of bariatric surgery has not been evaluated in patients with HF.

STUDY DESIGN

The National Surgical Quality Improvement Project (NSQIP) database for 2006-2014 was queried to identify patients undergoing adjustable gastric band, gastric bypass, sleeve gastrectomy, and biliopancreatic diversion-duodenal switch. Patients with HF were propensity matched to a control group without HF (1:5). Univariate analyses evaluated differences in complications, and multivariate analysis was completed to predict all-cause morbidity.

RESULTS

There were 237 patients identified with HF (mean age 52.8 years, 59.9% female, mean body mass index 50.6 kg/m²) matched to 1185 controls without HF who underwent bariatric surgery. Preoperatively, patients with HF were more likely to be taking antihypertensive medication and have undergone prior percutaneous cardiac intervention and cardiac surgery. There was no difference in operative time, surgical site infections, acute renal failure, re-intubation, or myocardial infarction. HF was associated with increased likelihood of length of stay more than 7 days, likelihood to remain ventilated > 48 h, venous thromboembolism, and reoperation. For patients with HF, the adjusted odds ratio for all-cause morbidity was 2.09 (1.32-3.22).

CONCLUSION

The NSQIP definition of HF, which includes recent hospitalization for HF exacerbation or new HF diagnosis 30 days prior to surgery, predicts a more than two-fold increase in odds of morbidity following bariatric surgery. This must be balanced with the longer-term potential benefits of weight loss and associated improvement in cardiac function in this population.

The Neutrophil-Lymphocyte Ratio and Survival During Left Ventricular Assist Device Support

BACKGROUND

Systolic heart failure (HF) is a low-grade systemic inflammatory state. Neutrophil-lymphocyte ratio (NLR) is a nonspecific inflammatory marker with prognostic value in HF. We aimed to determine the relationship between NLR and mortality during left ventricular assist device (LVAD) support.

METHODS AND RESULTS

We retrospectively reviewed LVAD recipients implanted in the years 2010-2018. NLR was recorded before LVAD implantation and at intervals during LVAD support; pre-LVAD and 90-day LVAD NLRs were compared. Cox proportional hazard models were constructed to study the impact of NLR, both before LVAD implantation and at 90 days with LVAD, on mortality during subsequent LVAD support. Among 301 subjects, the median pre-LVAD NLR was 4.7 (interquartile range 3.0-8.0). Higher pre-LVAD NLR was independently associated with increased mortality during a median 324 days of LVAD support (adjusted hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.01-1.06; P = .012, adjusted for pre-LVAD age, HF etiology, white blood count, hemoglobin, blood urea nitrogen, and sodium). After LVAD implantation, the NLR rose initially and then plateaued lower by day 90. Despite the mean decrease, higher 90-day LVAD NLR remained independently associated with increased mortality (adjusted HR 1.06, 95% CI 1.01-1.13; P = .033, stratified by early infection events).

CONCLUSIONS

Higher pre-LVAD NLR is independently associated with mortality during LVAD support. NLR improves during LVAD support, but even accounting for early infections, a higher NLR at day 90 remains associated with subsequent mortality.

Correlation of Paraoxonase-1 with the Severity of Crohn's Disease

Diagnostics of Crohn’s disease (CD) requires noninvasive biomarkers facilitating early detection and differentiation of the disease. Therefore, in this study, we aimed to determine the relationship between paraoxonase-1 (PON-1), the severity of CD, oxidative stress, and inflammation in CD. The CD activity index was based on the current classification. Plasma PON-1 was measured in 47 patients with CD, and in 23 control volunteers. Using quantitative variables such as receiver operating characteristics (ROC) (area under the curve (AUC)), the diagnostic utility of PON-1 in differentiating the severity of CD was assessed. Circulating PON-1 was found to be decreased in the CD group compared to the control group (269.89 vs. 402.56 U/L, respectively), and it correlated well with the disease activity. PON-1 correlated positively with hemoglobin (Hb) (r = 0.539, p < 0.001), hematocrit (Ht) (r = 0.48, p < 0.001), total cholesterol (TC) (r = 0.343, p < 0.001), high density lipoprotein (HDL) (r = 0.536, p < 0.001), low density lipoprotein (LDL) (r = 0.54, p < 0.001), and triglyceride (TG) (r = 0.561, p < 0.001) and correlated negatively with white blood cell count (WBC) (r = −0.262, p = 0.029), platelet count (PLT) (r = −0.326, p = 0.006), C-reactive protein (CRP) (r = −0.61, p < 0.001), and malondialdehyde (MDA) (r = −0.924, p < 0.001). PON-1 as a marker for CD differentiation possessed a sensitivity and specificity of 93.62% and 91.30%, respectively. CD was found to be associated with the decrease in the levels of PON-1, which correlates well with activity of the disease and reflects the intensification of inflammation, as well as intensified lipid peroxidation. High sensitivity and specificity of PON-1 determines its selection as a good screening test for CD severity.