The effects of glucagon like peptide-1 (GLP-1) on cardiac remodeling: exploring the role of medication and physiological modulation after metabolic surgery.

Obesity and associated comorbidities reach epidemic proportions nowadays. Several treatment strategies exist, but bariatric surgery has the only longstanding effects. Since a few years, there is increasing interest in the effects of gastro-intestinal hormones, in particular Glucagon-Like Peptide-1 (GLP-1) on the remission of Type 2 Diabetes (T2DM) and its effects on cardiac cardiovascular morbidity, cardiac remodeling, and mortality. In the past years several high quality multicenter randomized controlled trials were developed to assess the effects of GLP-1 receptor agonist therapy on cardiovascular morbidity and mortality. Most of the trials were designed and powered as non-inferiority trials to demonstrate cardiovascular safety. Most of these trials show a reduction in cardiovascular morbidity in patients with T2DM. Some follow-up studies indicate potential beneficial effects of GLP-1 receptor agonists on cardiovascular function in patients with heart failure, however the results are contradictory, and we need long-term studies to make firm conclusions about the pleiotropic properties of incretin-based therapies. However, it seems that GLP-1 receptor agonists have different effects than the increased GLP-1 production after bariatric surgery on cardiovascular remodeling. One of the hypotheses is that the blood concentrations of GLP-1 receptor agonists are three times higher compared to GLP-1 increase after bariatric and metabolic surgery. The purpose of this narrative review is to summarize the effects of GLP-1 on cardiovascular morbidity, mortality and remodeling due to medication but also due to bariatric and metabolic surgery. The second objective is to explain the possible differences in effects of GLP-1 agonists and bariatric and metabolic surgery.

Quality assessment of robot assisted thoracic surgical resection of non-small cell lung cancer: nodal upstaging and mediastinal recurrence.

BACKGROUND: Robot assisted thoracic surgery (RATS) is the minimally invasive surgical technique of choice for treatment of patients with non-small cell lung cancer (NSCLC), at the Isala Hospital. The aim of this study is to compare clinical and pathological staging results and mediastinal recurrence after RATS for anatomical resections of lung cancer as surrogate markers for quality of mediastinal lymph node dissection (MLND). METHODS: This single institute retrospective study was conducted in patients who underwent RATS for NSCLC. Excluded were patients with a history of concurrent malignant disease, with other previous neoplasms, with small cell lung cancer (SCLC) and patients in whom the robotic technique was converted to thoracotomy, prior to lymph node dissection. Data were obtained from the hospital database. The difference between clinical and pathological staging was expressed as upstaging and downstaging. Computed Tomography scanning was used for follow-up, and diagnosis of mediastinal recurrence. RESULTS: From November 2011 to May 2016, 227 patients underwent RATS at Isala Hospital Zwolle, the Netherlands. Of those, 130 (mean age, 69.5±9.3 years) met the eligibility criteria. Preoperative mediastinal lymph node staging was done by endoscopic ultrasound/endobronchial ultrasound, by positron emission tomography (PET) or mediastinoscopy. In 14 patients (10.8%) unforeseen N2 disease was found, 6 patients (4.6%) were upstaged from cN0 to pN2 and 8 patients (6.2%) were upstaged from cN1 to pN2. Mediastinal recurrence was detected in 7 patients (5.4%) during a median follow-up of 54 months (range, 1.5-102 months). CONCLUSIONS: In patients with NSCLC, who underwent anatomical resection by means of RATS, an unforeseen N2 disease rate of 10.8% was demonstrated and a mediastinal recurrence rate of 5.4%. It is concluded that robotic surgery provides an accurate lymph node dissection.

Effects of Bariatric Surgery on Heart Rhythm Disorders: a Systematic Review and Meta-Analysis.

The aim of this systematic review is to provide an overview of the literature on the effects of bariatric surgery on obesity-associated electrocardiogram (ECG) abnormalities and cardiac arrhythmias. Fourteen studies were included with a methodological quality ranging from poor to good. Majority of the studies showed a significant decrease of QT interval and related measures after bariatric surgery. Seven studies were included in the meta-analysis on effects of bariatric surgery on QTc interval and a significant decrease in QTc interval of - 33.6 ms, 95%CI [- 49.8 to - 17.4] was seen. Bariatric surgery results in significant decrease in QTc interval and P-wave dispersion, i.e., a normalization of initial pathology. The effects on atrial fibrillation are conflicting and not yet fully understood.

Endothelial function in obesity and effects of bariatric and metabolic surgery.

INTRODUCTION: Due to the lifestyle changes and the on-going urbanization waves there is obesity pandemic. The visceral fatty tissue of patients with obesity, in comparison with subcutaneous fat, has more gene expression related to inflammation, oxidative stress, cytokine production, and angiogenesis. The abovementioned leads to a decrease in arteriolar function and also an impaired endothelial vasodilatation and eventually endothelial dysfunction. AREAS COVERED: This review aims to provide an overview of the pathophysiology of obesity and endothelial dysfunction and the effects after bariatric and metabolic surgery and the consequences of surgery for the endothelial function. In this review, we focussed and searched for literature in Pubmed and The Cochrane library (from the earliest date of each database until February 2020) regarding endothelial function, obesity, and effects of bariatric and metabolic surgery. EXPERT OPINION: Within cardiovascular research, the endothelium and its function have a prominent role and it is the responsibility of the researchers to unravel the pathophysiological mechanisms and potential new targets for treatment of cardiovascular diseases.

The Right Anterior Thoracotomy Approach to Resect a Cardiac Papillary Fibroelastoma of the Aortic Valve.

A cardiac papillary fibroelastoma (CPFE) is reported to be the second most common cardiac neoplasm after myxoma cordis. CPFEs are histologically benign, frequently asymptomatic, but highly thrombogenic, which could lead to systemic and peripheral embolization. We present a case of a 68-year-old-patient, with a history of angioosteohypertrophy syndrome, who presented at our emergency department (ED) with symptoms of transient ischemic attacks. A thorough investigation, including echocardiography, revealed a neoplasm on the left coronary cusp (LCC) of the aortic valve. The neoplasm was resected via a valve-sparing shave via the right anterior thoracotomy (RAT). The pathological assessment confirmed it to be CPFE. CPFE is a rare but treatable cause of thromboembolism. The removal of CPFEs has classically been performed through a full median sternotomy. We like to present the first case of a valve-sparing removal of a CPFE on the aortic valve through a RAT approach.

The usefulness of preoperative exercise therapy in patients scheduled for lung cancer surgery; a survey among Dutch pulmonologists and cardiothoracic surgeons.

BACKGROUND: Preoperative exercise training (PET) studies show promising results in various patient populations. However, the lack of standardised programmes and uniformity in practice guidelines are barriers for implementation. Aim of this study was to assess the current opinions of pulmonologists and cardiothoracic surgeons on the clinical applicability of PET in patients scheduled for lung cancer surgery. METHODS: Dutch pulmonologists and cardiothoracic surgeons were asked to complete a 29-question survey regarding PET as an additional option to further optimise the health status of patients scheduled for lung cancer surgery. RESULTS: In total, 47 respondents (63% response rate), including 30 pulmonologists and 11 cardiothoracic surgeons and 6 residents in training completed the survey. A vast majority of the respondents had a positive attitude towards PET. Home-based exercise was considered less useful, as well as unsupervised exercise. Patient's motivation, improvements in physical capacity and quality of life, and lifestyle adjustments are important factors for the success of PET. The programme should at least contain inspiratory muscle training (95.7%), lifestyle interventions (95.7%), and supervised exercise training (91.5%). Cardiac and pulmonary risk assessment and medication assessment and optimisation were found less important. CONCLUSION: Among pulmonologists and cardiothoracic surgeons, there is a tendency that PET can be a valuable addition to the perioperative care of lung surgery patients. Points of discussion are the contents of PET programmes, and there seems to be a lack of awareness among chest physicians.

Cardiac remodeling in obesity and after bariatric and metabolic surgery; is there a role for gastro-intestinal hormones?

Introduction: Obesity is associated with various diseases such as type 2 diabetes, hypertension, obstructive sleep apnea syndrome (OSAS), metabolic syndrome, and cardiovascular diseases. It affects several organ systems, including the pulmonary and cardiac systems. Furthermore, it induces pulmonary and cardiac changes that can result in right and/or left heart failure.Areas covered: In this review, authors provide an overview of obesity and cardiovascular remodeling, the individual actions of the gut hormones (like GLP-1 and PYY), the effects after bariatric/metabolic surgery and its influence on cardiac remodeling. In this review, we focussed and searched for literature in Pubmed and The Cochrane library (from the earliest date until April 2019), regarding cardiac function changes before and after bariatric surgery and literature regarding changes in gastrointestinal hormones.Expert opinion: Regarding the surgical treatment of obesity and metabolic diseases there is recognition of the importance of both weight loss (bariatric surgery) and improvement in metabolic milieu (metabolic surgery). A growing body of evidence further suggests that bariatric surgical procedures [like the Sleeve Gastrectomy (SG), Roux-en Y Gastric Bypass (RYGB), or One Anastomosis Gastric Bypass (OAGB)] have can improve outcomes of patients suffering from a number of cardiovascular diseases, including heart failure.

Utility of preoperative exercise therapy in reducing postoperative morbidity after surgery; a clinical overview of current evidence.

Introduction: Surgery is a major stressor especially for older patients that are prone for postoperative complications and mortality. Hospitalization due to surgery and illness can be major life events, and the age-related impairments in physiological function and the decreased ability to respond to metabolic and hormonal perturbations in response to surgery often lead to a longer convalescence. Areas covered: This article gives an overview of the effects of PET in various surgical fields and also what to account for and expect of PET after various types of surgery. A comprehensive literature search was performed in Pubmed, Embase, Medline, Cochrane Library, and PEDro database (from the earliest date of each database to March 2019) using search words 'Preoperative Exercise Therapy', 'Physical Therapy' and 'surgery'. Secondly, the literature searches were modified depending on the surgical specialty. Expert opinion: Evidence is growing that preoperative exercise therapy in various surgical specialties is well tolerated and effective, with by far the most evidence in the cardiac surgical field. Future improvements in standards of care and optimal pre-operative preparation should not only focus on the surgical team and the hospital organization but also on incorporating the active role of the patient.

Utility of the cold pressor test to predict future cardiovascular events.

INTRODUCTION: The cold pressor test (CPT) is a common and extensively validated test, which induces systemic stress involving immersion of an individual's hand in ice water (normally temperature between 0 and 5 degrees Celsius) for a period of time. CPT has been used in various fields, like examining effects of stress on memory, decision-making, pain and cardiovascular health. Areas covered: In terms of cardiovascular health, current research is mainly interested in predicting the occurrence of cardiovascular (CV) events. The objective of this review is to give an overview of the history and methodology of the CPT, and clinical utility in possibly predicting CV events in CAD and other atherosclerotic diseases. Secondly, we will discuss possible future applications of the CPT in clinical care. Expert opinion: An important issue to address is the fact that the physiology of the CPT is not fully understood at this moment. As pointed out multiple mechanisms might be responsible for contributing to either coronary vasodilatation or coronary vasoconstriction. Regarding the physiological mechanism of the CPT and its effect on the measurements of the carotid artery reactivity even less is known.

Interaction of obesity and atrial fibrillation: an overview of pathophysiology and clinical management.

INTRODUCTION: Obesity, defined as a Body Mass Index (BMI) of ≥30 kg/m2, is the most common chronic metabolic disease worldwide and its prevalence has been strongly increasing. Obesity is associated with various diseases such as cardiovascular disease, type 2 diabetes, and hypertension. Regarding heart rhythm disorders, obesity is associated with an increase in atrial fibrillation (AF), the most common arrhythmia in clinical practice. AF is associated with increased cardiovascular morbidity and mortality. Obesity, a novel risk factor, is responsible for a 50%-increased incidence of AF. Areas covered: We will briefly discuss the obesity paradox and its mechanisms regarding cardiac and hemodynamic function changes. In the first main part of this review, we will be discussing risk assessment studies, pathophysiology, genetic predisposition, epicardial adipose tissue, and ventricular adaptation in relation to obesity and development of AF. In the second part, we will discuss treatment strategies like conservative management and the effect of bariatric and metabolic surgery. Expert opinion: Cardiac arrhythmias, in particular, AF, in patients with obesity comprise complex pathophysiological mechanisms that remain poorly understood. In recent literature, there has been increased interest in the role of epicardial adipose tissue and structural remodeling in obese hearts.