Outcomes and predictors of recovery in acute-onset cardiomyopathy: A single-center experience of patients undergoing endomyocardial biopsy for new heart failure.

BACKGROUND: About one-third of patients with unexplained acute-onset heart failure (HF) recover left ventricular (LV) function; however, characterization of these patients in the setting of contemporary HF therapies is limited. We aim to describe baseline characteristics and predictors of recovery in patients with acute-onset cardiomyopathy. METHODS: We previously described 851 patients with unexplained HF undergoing endomyocardial biopsy. In this study, 235 patients with acute-onset HF were further retrospectively examined. RESULTS: Follow-up LV ejection fraction (LVEF) was available for 138 patients. At 1 year, 48 of 138 (33%) had LVEF recovery (follow-up LVEF ≥50%), and 90 of 138 (65%) had incomplete or lack of recovery. Higher cardiac index (P=.019), smaller LV diastolic diameter (P=.002), and lack of an intraventricular conduction delay (IVCD) (P=.002) were associated with LVEF recovery. IVCD (P=.001) and myocarditis (P=.016) were independent predictors of the composite end point of death, LV assist device placement, and/or transplant at 1 year. Those with an IVCD had a significantly lower 1-year survival than those without (P=.007). CONCLUSIONS: Patients with a smaller LV end-diastolic diameter, higher cardiac index, and lack of IVCD at presentation for acute-onset HF were more likely to have LVEF recovery. IVCD was a poor prognostic marker in all patients presenting with acute cardiomyopathy.

The impact of failed novel technology and technical errors on the revision burden in total hip arthroplasty: what percentage of revision hip arthroplasty was potentially avoidable?

BACKGROUND: Despite the high success rate of total hip arthroplasty (THA), new implant technologies continue to be developed. Although potentially useful, such novel developments may result in unintended consequences, leading to revision surgery, often prematurely. In several instances, new technology that appeared promising was later found to be inferior to existing technology and resulting in early revision surgery. Additionally, technical surgical errors may also lead to early revisions. Some have argued that revisions related to such phenomena are potentially avoidable. The present analysis investigates to what extent the contribution of "failed new technology" and "technical errors" contributes to the revision burden and to the need for premature revision arthroplasty. METHODS: We retrospectively analysed 432 revision THAs and categorised them as either "late revisions" based on survivorship of 10 years or "premature revisions". Among both cohorts, we determined what percentage of revisions were potentially avoidable and due to failed novel technologies and technical errors, and what percent were "unavoidable". RESULTS: Of the 432 revisions, 267 (62%) were considered premature and 38% were considered late. Of the premature revisions, 108 were considered potentially avoidable (81 failed novel technologies, 27 technical errors). CONCLUSIONS: Our data demonstrates that new technology and surgical techniques can result in premature failure of THA. Surgeons should take caution when incorporating new implant technology or surgical techniques into their practice.

Repeated administration of AMPA or a metabotropic glutamate receptor agonist into the rat ventral tegmental area augments the subsequent behavioral hyperactivity induced by cocaine.

RATIONALE: Glutamate receptors and their related second messengers in the ventral tegmental area (VTA) are known to play critical roles in the initiation of behavioral sensitization to cocaine. OBJECTIVES: To evaluate the hypothesis that repeated intra-VTA microinjections of the ionotropic glutamate agonist, AMPA, or the metabotropic glutamate agonist, t-ACPD, augment the behavioral hyperactivity induced by a subsequent challenge injection of cocaine. In addition, the dependency of the t-ACPD effect on activation of the calcium/calmodulin-dependent kinases (CaM-Ks) was assessed. METHODS: Male Sprague-Dawley rats received four once-daily microinjections of saline, AMPA, t-ACPD, or t-ACPD plus the CaM-KII inhibitor KN-93 directly into the VTA; locomotor activity was measured for 120 min after each of the daily treatments. One week after the 4 treatment days, all animals received a challenge injection of cocaine (15 mg/kg, IP) and behavioral activity was monitored for 120 min. RESULTS: Intra-VTA administration of t-ACPD increased behavioral activity only on the first 2 treatment days, an effect that was blocked by pre-treatment with KN-93. Administration of AMPA into the VTA, in contrast, produced behavioral hyperactivity that sensitized over the 4 treatment days. Following the cocaine challenge injection, there was an augmentation of cocaine-induced behavioral hyperactivity in the groups pretreated with AMPA or t-ACPD but not in the animals administered t-ACPD plus KN-93. CONCLUSIONS: These results indicate that repeated stimulation of AMPA or metabotropic glutamate receptors in the VTA mimics the initiation of behavioral sensitization to cocaine. The present findings also suggest that glutamate agonist-induced activation of CaM-KII in the VTA plays a critical role in the behavioral and neuronal plasticity induced by repeated cocaine injections.

Renal Complications in Patients Undergoing Transcatheter Aortic Valve Replacement.

Acute kidney injury in hospitalized patients is associated with significantly increased mortality across a broad spectrum of conditions. According to the Society of Thoracic Surgeons database, patients with chronic kidney disease undergoing surgical aortic valve replacement with or without coronary artery bypass grafting had a more than 50% reduction in observed 8-year survival compared with those without chronic kidney disease. Transcatheter aortic valve replacement is an exciting new approach for the treatment of aortic stenosis in high-risk or inoperable patients with severe aortic stenosis. This article discusses the incidence, predictors, impact, and potential avoidance and management strategies of renal dysfunction associated with transcatheter aortic valve replacement.

Evaluation of the role of endomyocardial biopsy in 851 patients with unexplained heart failure from 2000-2009.

BACKGROUND: Endomyocardial biopsy (EMB) is often considered when the pathogenesis of heart failure cannot be determined by noninvasive testing. Uncertainty remains about the diagnostic and clinical use of EMB in various clinical scenarios. METHODS AND RESULTS: We examined the characteristics of a cohort of patients with unexplained heart failure who underwent EMB at a tertiary care medical center. We categorized each patient into a clinical scenario as outlined by the 2007 AHA/ACC/ESC guidelines and determined the number of times EMB provided a diagnosis or altered the clinical course. A total of 851 patients underwent EMB from 2000-2009. Overall, 25.5% of EMBs provided a diagnosis and 22.7% of EMBs changed clinical course. Heart failure associated with unexplained restrictive cardiomyopathy was the most common clinical scenario, comprising 33.6% (286/851) of EMBs, and 84 (29.4%) of these EMBs were diagnostic. EMB for unexplained heart failure of <2 weeks duration had a diagnostic yield at 35% (39/109). There were 4 uncommon scenarios where EMB had a high diagnostic and clinical yield. There were 16 complications for an overall rate of 1.9%. CONCLUSIONS: We confirm that EMB is useful in acute onset unexplained cardiomyopathy. We demonstrate a role for EMB in suspected infiltrative disease and in the management of rare clinical scenarios, such as suspected hypersensitivity myocarditis, anthracycline cardiomyopathy, cardiac tumors, and arrhythmogenic right ventricular dysplasia/cardiomyopathy. Our results suggest low use of EMB in chronic heart failure that responds to usual care.

Increased lipofuscin on endomyocardial biopsy predicts greater cardiac improvement in adolescents and young adults.

BACKGROUND: The presence of interstitial fibrosis and lipofuscin in endomyocardial biopsies may indicate the chronicity of heart failure. Fibrosis is known to increase in the failing heart. Lipofuscin increases with age, but its relationship to heart function is unknown. This study investigated whether lipofuscin or fibrosis had predictive utility in indicating function or adverse event (death, transplant, assist device placement) at 1 year postbiopsy in adolescents and young adults. METHODS: A retrospective analysis was performed on nontransplant endomyocardial biopsies between 2000 and 2009 from individuals aged 10-40 years. Clinical and demographic information including ejection fraction (EF), EF at 1 year, and adverse events were obtained as available. Lipofuscin and fibrosis were scored retrospectively in a blinded fashion for 201 biopsies. Linear regression and Cox proportional hazard models were used for multivariable analysis. RESULTS: Increasing lipofuscin strongly correlated with patient age (P<.0001). Higher lipofuscin levels were correlated with a better EF at 1 year (P=.02). This remained significant (P=.04) after adjusting for age. The degree of fibrosis did not associate with any clinical variable and had no predictive capabilities in this study. CONCLUSIONS: This is the first study to incorporate lipofuscin in predicting future heart function. We found that more lipofuscin correlates with better EFs at 1 year, suggesting that lipofuscin is a marker for improved cardiac compensation. This information can help clinicians devise treatment plans for individuals in this age group.