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.

Implementation of a palliative care consultation trigger tool for hospitalised patients with acute decompensated heart failure.

Heart failure is a leading cause of hospitalisations. Integration of palliative care services with medical therapy in the management of hospitalised patients with heart failure is imperative. Unfortunately, there are no standardised criteria for palliative care referrals among hospitalised patients with acute decompensated heart failure. The objective of our quality improvement project was to develop and implement a palliative care consult trigger tool for hospitalised patients with acute decompensated heart failure. We found that among eligible patients, palliative care referrals were underused, likely contributing to misalignment of goals of care and suboptimal advance care planning. We developed a trigger tool and designed and implemented structured multicomponent educational interventions to improve the appropriateness and timeliness of inpatient palliative care consultations in this high-risk population. The educational interventions led to a significant increase in the rate of appropriate inpatient palliative care consultations among hospitalised patients with acute decompensated heart failure (46.3% vs 27.7%; p=0.02). In addition, palliative care referrals resulted in better alignment of goals of care at the time of hospital discharge, as measured by a significant increase in the completion rate of a healthcare proxy form (11.4% vs 47.2%; p<0.001) and a Medical Order for Life-Sustaining Treatment form (2.0% vs 24.1%; p<0.001), as well as the establishment of a Do-Not-Resuscitate order (2.7% vs 29.6%; p<0.001). Furthermore, the intervention resulted in a significant decrease in the hospital readmission rate up to 90 days post-discharge (43.6% vs 8.3%; p<0.001). This quality improvement project calls for the development and adoption of standardised criteria for palliative care referrals to benefit hospitalised patients with heart failure and reduce symptom burden, align goals of care and improve quality of life.

Hemodynamic and Clinical Performance of Hearts Donated After Circulatory Death.

BACKGROUND: Donor organ demand continues to outpace supply in heart transplantation. Utilization of donation after circulatory death (DCD) hearts could significantly increase heart donor availability for patients with advanced heart failure. OBJECTIVES: The purpose of this study was to describe hemodynamic and clinical profiles of DCD hearts in comparison to standard of care (SOC) hearts donated after brain death (DBD). METHODS: This single-center retrospective cohort study of consecutive heart transplant recipients analyzed right heart catheterization measurements, inotrope scores, echocardiograms, and clinical outcomes between DCD and DBD heart recipients. RESULTS: Between April 2016 and February 2022, 47 DCD and 166 SOC hearts were transplanted. Median time from DCD consent to transplant was significantly shorter compared with SOC waiting list time (17 days [6-28 days] vs 70 days [23-240 days]; P < 0.001). Right heart function was significantly impaired in DCD recipients compared with SOC recipients 1 week post-transplant (higher median right atrial pressure (10 mm Hg [8-13 mm Hg] vs 7 mm Hg [5-11 mm Hg]; P < 0.001), higher right atrial pressure to pulmonary capillary wedge pressure ratio (0.64 [0.54-0.82] vs 0.57 [0.43-0.73]; P = 0.016), and lower pulmonary arterial pulsatility index (1.66 [1.27-2.50] vs 2.52 [1.63-3.82]; P < 0.001), but was similar between groups by 3 weeks post-transplant. DCD and SOC recipient mortality was similar at 30 days (DCD 0 vs SOC 2%; P = 0.29) and 1 year post-transplant (DCD 3% vs SOC 8%; P = 0.16). CONCLUSIONS: DCD heart utilization is associated with transient post-transplant right heart dysfunction and short-term clinical outcomes otherwise similar to transplantation using DBD hearts.

Treatment of cardiac resynchronization therapy non-responders: current approaches and new frontiers.

INTRODUCTION: Cardiac resynchronization therapy (CRT) has developed into a very effective technology for patients with decreased systolic function and has substantially improved patients' clinical course. However, non-responsiveness to CRT, described as lack of reverse cardiac chamber remodeling, leading to lack to improve symptoms, heart failure hospitalizations or mortality, is common, rather unpredictable, and not fully understood. AREAS COVERED: This article aims to discuss key factors that are impacting CRT response, from patient selection to LV lead position, to structured follow-up in CRT clinics. Secondly, common causes and interventions for CRT non-responsiveness are discussed. Next, insight is given into technologies representing new and feasible interventions as well as pacing strategies in this group of patients that remain challenging to treat. Finally, an outlook is given into future scientific development. EXPERT OPINION: Despite the progress that has been made, CRT non-response remains a significant and complex problem. Patient management in interdisciplinary teams including heart failure, imaging, and cardiac arrhythmia experts appears critical as complexity is increasing and CRT non-response often is a multifactorial problem. This will allow optimization of medical therapy, and the use of new integrated sensor technologies and telemedicine to ultimately optimize outcomes for all patients in need of CRT.

Response by Sex in Patient-Centered Outcomes With Baroreflex Activation Therapy in Systolic Heart Failure.

OBJECTIVES: The aim of this study was to assess sex differences in the efficacy and safety of baroreflex activation therapy (BAT) in the BeAT-HF (Baroreflex Activation Therapy for Heart Failure) trial. BACKGROUND: Patients were randomized 1:1 to receive guideline-directed medical therapy (GDMT) alone (control group) or BAT plus GDMT. METHODS: Pre-specified subgroup analyses including change from baseline to 6 months in 6-min walk distance (6MWD), quality of life (QoL) assessed using the Minnesota Living With Heart Failure Questionnaire (MLWHQ), New York Heart Association (NYHA) functional class, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were conducted in men versus women. RESULTS: Fifty-three women and 211 men were evaluated. Women had similar baseline NT-proBNP levels, 6MWDs, and percentage of subjects with NYHA functional class III symptoms but poorer MLWHQ scores (mean 62 ± 22 vs. 50 ± 24; p = 0.01) compared with men. Women experienced significant improvement from baseline to 6 months with BAT plus GDMT relative to GDMT alone in MLWHQ score (-34 ± 27 vs. -9 ± 23, respectively; p < 0.01), 6MWD (44 ± 45 m vs. -32 ± 118 m; p < 0.01), and improvement in NYHA functional class (70% vs. 27%; p < 0.01), similar to the responses seen in men, with no significant difference in safety. Women receiving BAT plus GDMT had a significant decrease in NT-proBNP (-43% vs. 7% with GDMT alone; difference -48%; p < 0.01), while in men this decrease was -15% versus 2%, respectively (difference -17%; p = 0.08), with an interaction p value of 0.05. CONCLUSIONS: Women in BeAT-HF had poorer baseline QoL than men but demonstrated similar improvements with BAT in 6MWD, QoL, and NYHA functional class. Women had a significant improvement in NT-proBNP, whereas men did not. (Baroreflex Activation Therapy for Heart Failure [BeAT-HF]; NCT02627196).

Right and Left-Sided Carcinoid Heart Disease in the Setting of Selective Serotonin Reuptake Inhibitor Use.

Carcinoid heart disease is a complication of carcinoid syndrome. The role of selective serotonin reuptake inhibitors in carcinoid heart disease is unclear. We present a case of refractory heart failure due to right- and left-sided carcinoid heart disease in the setting of selective serotonin reuptake inhibitor use despite remission of carcinoid syndrome. (Level of Difficulty: Beginner.).

Subcutaneous furosemide for the treatment of heart failure: a state-of-the art review.

The prevalence of heart failure (HF) is on the rise. By 2030, over eight million Americans (46% increase from current prevalence) will have heart failure. In the USA, approximately 30 billion dollars is spent annually on heart failure and this number will likely double in 2030. Thus, HF represents a significant economic burden. Acute decompensated heart failure (ADHF) is a clinical spectrum, which refers to increasing symptoms and signs of heart failure prompting an emergency room visit or hospitalization. In ADHF, inpatient administration of intravenous diuretic is the standard of care due to the variability in the absorption of oral diuretics. Within 30 days, 25-30% of these patients are readmitted with recurrent ADHF. Recent efforts have focused in reducing HF readmission, and thereby decreasing costs; hence, innovative outpatient treatment options have emerged. Subcutaneous furosemide use will potentially overcome the need to place intravenous lines, reduce associated expenses, and enable management of ADHF at home. This review presents data on the pharmacodynamics and pharmacokinetics of subcutaneous furosemide, scientific evidence on the use of this therapy in the palliative and hospice population, and its experimental use as an outpatient therapy and/or as a bridge from inpatient to home.

Implantable devices for heart failure monitoring and therapy.

Heart failure (HF), the cardiovascular epidemic of the twenty-first century, is associated with significant comorbidities and high mortality. The prevalence of HF is estimated around 6.5 million people and is expected to increase to 8 million by the year 2030. The associated costs to care for these patients continue to increase. Despite the advancement of pharmacologic therapy with significant improvement in morbidity and mortality, the 5-year survival for heart failure still stands at 61%. The challenges faced by HF patients include difficulty with lifestyle modifications, nonadherence to complex medical regimens, financial limitations, lack of access to medical care, and unfavorable side effects. The sickest HF patients, who are ACC/AHA stage D, have advanced therapeutic options such as left ventricular assist devices and orthotopic heart transplant; however, the majority of patients are ACC/AHA stage C and/or not candidates for such advanced care. With constraints placed on hospitals by Medicare on HF readmissions as well as the multiple comorbidities imposed by this disease, intense interest is focused on the development of implantable devices as add-on therapy. This review discusses the innovative devices under varying stages of investigation or approved for monitoring and treatment of HF.

The dilemma of implantable cardioverter-defibrillator therapy in the geriatric population.

Current guidelines for implantable cardioverter-defibrillator (ICD) therapy in heart failure patients were established by multiple device trials; however, very few geriatric patients (patients ≥ 65 years old) were included in these studies. This article explores the controversies of ICD implantation in the geriatric population, management of delivered ICD therapy in this age group, and the end of life care in patients with ICD.

Higher rate of comorbidities after cardiac retransplantation contributes to decreased survival.

BACKGROUND: Cardiac retransplantation is the definitive treatment for allograft failure despite decreased long-term survival in these patients. The cause of the poorer outcomes in cardiac retransplant patients is unclear. METHODS: This study was a retrospective analysis of 859 adult cardiac transplant patients. Of these, 45 (5.7%) underwent cardiac retransplantation at 8.2 +/- 5.3 (mean +/- SD) years after the first transplant, primarily for severe transplant vasculopathy (n = 42). RESULTS: One-year survival for retransplant patients was significantly lower compared with de novo transplant patients (75% vs 87%; p < 0.003). Twenty-three patients died due to either malignancy (n = 8), infection (n = 6), rejection (n = 3), sudden death (n = 2), recurrent transplant coronary artery disease (n = 2) or post-operative bleeding (n = 1). CONCLUSION: Although cardiac retransplantation has immediate life-saving benefits, survival is lower compared with de novo cardiac transplantation due to higher rates of malignancy and infection.

Enhancing repair of the mammalian heart.

The injured mammalian heart is particularly susceptible to tissue deterioration, scarring, and loss of contractile function in response to trauma or sustained disease. We tested the ability of a locally acting insulin-like growth factor-1 isoform (mIGF-1) to recover heart functionality, expressing the transgene in the mouse myocardium to exclude endocrine effects on other tissues. supplemental mIGF-1 expression did not perturb normal cardiac growth and physiology. Restoration of cardiac function in post-infarct mIGF-1 transgenic mice was facilitated by modulation of the inflammatory response and increased antiapoptotic signaling. mIGF-1 ventricular tissue exhibited increased proliferative activity several weeks after injury. The canonical signaling pathway involving Akt, mTOR, and p70S6 kinase was not induced in mIGF-1 hearts, which instead activated alternate PDK1 and SGK1 signaling intermediates. The robust response achieved with the mIGF-1 isoform provides a mechanistic basis for clinically feasible therapeutic strategies for improving the outcome of heart disease.

Does renal function deteriorate more rapidly in diabetic cardiac transplant recipients?

BACKGROUND: Selection criteria for cardiac transplant candidates with diabetes mellitus (DM) have been liberalized resulting in increased numbers of diabetic patients receiving organs. Calcineurin inhibition results in nephrotoxicity. Whether this nephrotoxicity is accelerated in diabetic heart transplant recipients is unknown. METHODS: To investigate this question, we derived the glomerular filtration rate (GFR) at transplant and at multiple time intervals thereafter for adult heart transplants performed from January 1, 2000 to January 1, 2005. GFR was estimated using the Modification of Diet in Renal Disease Study equation (GFRMDRD) and the Cockcroft-Gault (GFRCG) formula. RESULTS: In all, 257 patients were nondiabetic and 102 patients were diabetic before and after transplant. The diabetic patients were older (57+/-8 vs. 53+/-13 years; P<0.01) and had greater body mass index (27.5+/-5.1 vs. 25.5+/-4.4 kg/m; P<0.01) than nondiabetic patients. Baseline renal function was significantly reduced in diabetic patients with higher serum creatinine (1.6+/-0.5 vs. 1.4+/-0.5 mg/dL), lower GFRCG (65+/-27 vs. 73+/-35 mL/min), and lower GFRMDRD (54+/-23 vs. 65+/-32 mL/min; all P<0.01) than nondiabetic patients. All patients were treated with cyclosporine or tacrolimus posttransplant. The change in the GFRMDRD in nondiabetic and diabetic patients was constant and comparable at 1, 2, and 3 years posttransplant. In normal subjects, GFRMDRD declined from baseline by 7+/-26, 5+/-23, and 7+/-23 mL/min(2) and in the diabetic patients was 13+/-22, 9+/-26, 10+/-22 ml/min(2) at 1, 2, and 3 years, respectively (P=NS). CONCLUSION: This data suggests that nephrotoxicity posttransplant is not accelerated in diabetic recipients.

Ease of noninvasive measurement of cardiac output coupled with peak VO2 determination at rest and during exercise in patients with heart failure.

Peak oxygen consumption (VO2) is a powerful prognostic predictor of survival in patients with heart failure (HF) because it provides an indirect assessment of a patient's ability to increase cardiac output (CO). However, many peripheral factors affect VO2. Inert gas rebreathing using low-concentration soluble and insoluble inert gases can derive CO by the Fick principle. The Innocor rebreathing system uses an oxygen-enriched mixture of an inert soluble gas (0.5% nitrous oxide) and an inert insoluble gas (0.1% sulfur hexafluoride) measured by photoacoustic analyzers over a 5-breath interval. The practicality of this device in measuring CO and VO2 during exercise was assessed in patients with HF. Ninety-two consecutive exercise tests were prospectively performed in 88 patients with HF using the Innocor system. Incremental bicycle exercise was performed with CO measurements at rest, at 50 W, and at peak exercise. The mean age of the 68 men and 20 women was 54 +/- 13 years; 33% had coronary artery disease, and 67% had dilated cardiomyopathy. The mean left ventricular ejection fraction was 24 +/- 9%. Patients were able to rapidly learn the rebreathing technique and easily integrate it into the exercise protocol. Eighty-six percent of the tests had successful measurement of metabolic and cardiac output data. Mean CO at rest was 3.5 +/- 1.1 L/min and increased to 7.2 +/- 2.7 L/min. Mean peak VO2 was 12.6 +/- 4.7 ml/kg/min. A significant linear correlation was observed between peak VO2 and peak CO (r = 0.64, p <0.0001). In conclusion, combined metabolic stress testing with inert gas rebreathing can be easily performed in patients with HF.

The association between blood pressure and mortality in patients with heart failure.

BACKGROUND: The association between low blood pressure and prognosis in the general population has been controversial, with some reports suggesting an increased mortality for patients with the lowest blood pressures. Whereas many standard heart failure therapies decrease blood pressure, the relationship between mortality and blood pressure in patients with heart failure has not been previously evaluated. METHODS: We used the Digitalis Investigation Group trial database to evaluate retrospectively the relationship among systolic blood pressure (SBP), diastolic blood pressure (DBP), and survival among 5747 patients with New York Heart Association class II or III heart failure and left ventricular ejection fraction < or = 0.45. Cox proportional hazards models were used to identify covariates predictive of long-term mortality. RESULTS: The adjusted all-cause mortality rate during the entire study period for patients in the lowest SBP group (< 100 mm Hg) was 50% and was significantly higher than that of the reference group of patients with SBP of 130 to 139 mm Hg, which had a mortality rate of 32% (hazard ratio 1.65, 95% CI 1.25-2.17, P < .001). The relationship between SBP and mortality was significant (P < .001) and nonlinear (P = .009). The relationship between DBP and mortality was significant (P < .001), with the highest mortality seen in patients with DBP < 60 mm Hg. CONCLUSIONS: In patients with systolic dysfunction (left ventricular ejection fraction < or = 0.45) and New York Heart Association classes II and III symptoms, lower SBPs and DBPs were associated with greater mortality.

Prognostic impact of diabetes mellitus in patients with acute decompensated heart failure.

The presence of diabetes mellitus (DM) adversely affects the natural history of heart failure (HF), but its prognostic significance is unknown in acute decompensated HF. Of the 498 patients enrolled with decompensated HF requiring intravenous vasoactive therapy, 236 (47.4%) had a previous diagnosis of DM. After 6 months, 113 patients (22.7%) had died. A Cox proportional-hazards model showed a significant association between DM and worse survival after hospital discharge. DM is common among patients admitted with decompensated HF, and diabetes-related biologic differences contribute to the progression of HF.

Nesiritide for the treatment of decompensated heart failure.

Heart failure is the leading cause of hospitalizations in the USA, and is associated with significant morbidity, mortality and resource utilization. Established therapies for chronic heart failure have been shown to improve outcomes, but treatment for decompensated heart failure remains largely empiric. Nesiritide (Natrecor) is a synthetic analog of human B-type natriuretic peptide, a peptide released by the ventricular myocardium in response to increased wall tension. The physiologic effects of human B-type natriuretic peptide include natriuresis, vasodilation and neurohormonal modulation. In clinical trials, nesiritide has been shown to decrease cardiac filling pressures, increase cardiac index, and improve the clinical status of patients with acute decompensated heart failure. Compared with other available intravenous agents for heart failure, nesiritide is effective, generally well-tolerated with few adverse effects, and does not require invasive monitoring during administration. Nesiritide has proven to be an effective new treatment for patients with decompensated heart failure.

Optimal timing of cardiac transplantation after ventricular assist device implantation.

OBJECTIVE: We sought to determine the influence of the interval from ventricular assist device implantation to cardiac transplantation on end-organ function and posttransplantation survival. METHODS: United Network for Organ Sharing data on 2692 heart transplantations performed in adult patients in the United States between October 1999 and March 2001 were reviewed. RESULTS: Seventeen percent (466) of adult heart transplant recipients were bridged to transplantation with a ventricular assist device. Almost half of patients with ventricular assist devices undergoing transplantation were upgraded to status 1A as a result of ventricular assist device-related complications occurring more than 30 days after ventricular assist device implantation. Creatinine and total bilirubin levels were less in patients undergoing transplantation after 2 to 4 weeks of mechanical support. One-year survival was higher in the nonventricular assist device than in the ventricular assist device group (85.7% vs 79.7%, P =.0004). Within the ventricular assist device group, survival was lower for patients undergoing transplantation within 2 weeks of ventricular assist device implantation compared with those undergoing transplantation later (74.2% vs 84.2 %, P =.03). One-year survival among patients supported with a ventricular assist device for more than 30 days without complications was 91.4%. Multivariate analysis demonstrated a significant independent effect of the time interval from ventricular assist device implantation to transplantation on posttransplantation mortality and suggested that a period of lowest risk might exist between 1 and 3 months after implantation. CONCLUSIONS: Survival after cardiac transplantation is influenced by the time interval from ventricular assist device insertion to transplantation. Survival is significantly lower when performed within 2 to 4 weeks of ventricular assist device implantation.

Heart failure: an epidemic of the 21st century.

Heart failure is the leading cause of hospital admission in patients over the age of 65 in the United States and one of the leading causes of morbidity, mortality, and resource utilization in this country. This diagnosis carries an ominous prognosis worse than most cancers, and the financial burden exceeds 25 billion dollars a year. With the aid of a plethora of drugs, devices, and complementary therapies, heart failure management and outcomes have improved. However, as the country ages and more people survive their myocardial infarctions, as well as develop hypertension and diabetes, the incidence of heart failure continues to escalate. Heart failure has become such a broad epidemic that the American College of Cardiology, in collaboration with the American Heart Association, has developed new guidelines to prevent the development of systolic heart failure, thus changing the emphasis from clinical assessment to detection, intervention, and prevention. Hypertension and diabetes mellitus, in particular, are targeted as major risk factors for heart failure. These guidelines consist of 4 stages and provide objective categorization and evidence-based treatment recommendations from the literature for each of the stages. Inroads were made in the fight against heart attacks by the formation of care teams. Similarly, care teams for early identification of patients at risk, development of algorithms and critical pathways, and practicing evidence-based medicine are all within our capabilities for the battle against heart failure. Toward this end, the National Coalition for the Management of Left Ventricular Dysfunction has been formed and invites you to join in this comprehensive project to impact on the course of the heart failure epidemic at www.nclvd.org.