Correction of hypovitaminosis D improved global longitudinal strain earlier than left ventricular ejection fraction in cardiovascular older adults after orthopaedic surgery.

BACKGROUND: Cardiovascular diseases and insufficient levels of vitamin D are risk factors for adverse surgical outcomes, and they are both commonly present among older adults undergoing orthopaedic surgery. Giving the cardiovascular effects of vitamin D, pre-operative diagnosis of hypovitaminosis D would be a valuable step for the implementation of supplementation protocols. We investigated if the normalization of serum 25 [OH] D could ameliorate cardiac performance of older adults suffering from cardiovascular diseases. METHODS: We enrolled 47 older adults scheduled for major orthopaedic surgery and suffering from hypovitaminosis D. Patients underwent 6-months calcifediol supplementation with a starting dose at first post-operative day of 50 µg/die in liquid preparation. Down-titration to 20 µg/die at 3-months assessment was planned. Cardiac performance was evaluated by measuring left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) during pre-operative assessments and at 1-month, 3-months, 6-months follow-ups. RESULTS: Six months of calcifediol supplementation were associated with a significant improvement of both LVEF (+ 3.94%; 95% CI: -4.0789 to -0.8232; P < 0.01) and GLS (+ 18.56%; Z = -5.895; P < 0.0001). CONCLUSIONS: Calcifediol supplementation normalized serum 25 [OH] D concentration after 1-month treatment. GLS offered better insights into myocardial contractile amelioration than LVEF, thus being useful for detecting earlier subclinical changes that may anticipate hemodynamic modifications.

Neutrophil gelatinase-associated lipocalin predicts worsening of renal function in acute heart failure: methodological and clinical issues.

BACKGROUND: Worsening of renal function (WRF) in acute heart failure (AHF) strongly predicts adverse clinical outcome. Plasma neutrophil gelatinase-associated lipocalin (NGAL) has been proposed as an earlier biomarker of tubular damage, but important methodological issues remain unsolved, particularly in AHF. METHODS AND RESULTS: In 30 consecutive patients admitted for AHF, 108 serum NGAL (Alere system) measurements were performed at entry and in the first days of recovery, and reproducibility within the same blood samples was very high (r = 0.98). NGAL at entry was related to kidney function [r = 0.51 vs. creatinine (Cr) and r = -0.49 vs. estimated glomerular filtration rate (eGFR), both P < 0.001], and weakly with hemoglobin (r = -0.36, P < 0.05) and C-reactive protein (CRP) (r = 0.26, P < 0.05). During hospitalization, WRF occurred in 26.7% of the patients. Baseline NGAL was only slightly higher in patients who developed WRF as compared to those who did not (151 ±â€Š90 vs. 119 ±â€Š75 ng/ml, NS), but it increased significantly in the following days, always preceding WRF occurrence (max. previous 24 h, average 95%, range 25-200%). The area under the Receiver Operating Characteristic (ROC) curve (AUC-ROC) was 0.69 for pathological NGAL at entry and 0.91 for delta NGAL changes during the first days. CONCLUSIONS: In patients with AHF, serum NGAL measurement is highly reproducible and at entry it is related to baseline Cr and eGFR, but does not predict WRF during subsequent hospitalization. On the contrary, serial measurements of NGAL in the first days of hospitalization can accurately predict WRF.

Three years of cardiac resynchronization therapy: could superior benefits be obtained in patients with heart failure and narrow QRS?

AIM OF THE STUDY: To examine the long-term effects of cardiac resynchronization therapy (CRT) in patients presenting with heart failure (HF) and QRS 120 ms in the remaining 331 patients. The baseline characteristics of the 2 groups were similar. We evaluated indices of cardiac function, percentage of responders, and survival rates over a mean 28-month follow-up. RESULTS: Both groups experienced similar long-term increases in 6-MHW, and decreases in New York Heart Association functional class and LV end-systolic volume (all comparisons P < 0.0001 in both groups). Time interaction of changes in LVEF and percentage of responders were significantly different (P = 0.03 and P = 0.004, respectively), in favor of the narrow QRS group, where the changes were sustained and persisted at 2 and 3 years. The long-term death rate from HF was lower in the group with narrow than in the group with wide QRS complex (P = 0.04; log-rank test). CONCLUSIONS: CRT confers considerable long-term clinical, functional, and survival benefits in patients presenting with HF and narrow QRS, not preselected by echocardiographic criteria of dyssynchrony. Caution is advised before denying CRT to these patients on the basis of QRS width only.

Delayed defibrillation testing in patients implanted with biventricular ICD (CRT-D): a reliable and safe approach.

BACKGROUND: Defibrillation testing (DT) at the end of the implantation of cardiac resynchronization pacemaker with a defibrillator (CRT-D) exposes heart failure (HF) patients to increased procedural risks. However, until now, delayed DT has not been assessed as a possible option in HF patients implanted with CRT-D. OBJECTIVE: Aim of the present study is to assess safety and feasibility of delayed DT in HF patients treated with CRT-D. MATERIAL AND METHODS: Two hundred and eleven consecutive patients (mean age: 65 years, mean NYHA class 3.0, mean EF: 29.3%) underwent CRT-D implantation from October 1999 to December 2004. In the first 17 patients, DT was performed at the end of CRT-D implantation. In the other 194 consecutive patients, DT was performed at 2 months after CRT-D implantation. Outcome of DT, as well as "acute" LV lead dislodgment rate were evaluated in the latter group of 194 patients undergoing a delayed DT. Also, ICD function was assessed through device telemetry analysis at 2 months. RESULTS: At delayed DT, first shock was effective in 187 of 194 patients (96%), ineffective VF interruption at maximum energy occurred only in one patient (0.5%), and acute LV lead dislodgment was 1%. No ICD therapy failure occurred in the 2-month untested period. CONCLUSION: DT performed 2 months after CRT-D implantation is safe and feasible; this is possibly related to the improvement of clinical conditions and hemodynamic status as well as greater lead stability 2 months after CRT-D.