RESUMO
Pulmonary arterial hypertension (PAH) is a progressive and life-threatening disease characterized by elevated pulmonary vascular resistance, which results in right-heart failure. We present a case of interferon (IFN)-α-induced PAH developed after living donor liver transplantation. Although IFN is categorized as a "possible" risk factor for PAH in the current international classification, it is still under recognized. Moreover, the prognosis of IFN-induced PAH is poor in the limited number of published cases. In our case, we achieved good outcome by the withdrawal of IFN and administration of combination therapy using tadalafil, beraprost, and treprostinil. Since IFN is an important treatment option in current medical therapy, its contribution to the pathogenesis of PAH should be taken into consideration. In conclusion, our case suggests the importance of PAH screening in patients treated with IFN.
Assuntos
Pressão Arterial/efeitos dos fármacos , Hipertensão Pulmonar/induzido quimicamente , Fatores Imunológicos/efeitos adversos , Interferon-alfa/efeitos adversos , Transplante de Fígado/efeitos adversos , Doadores Vivos , Artéria Pulmonar/efeitos dos fármacos , Anti-Hipertensivos/uso terapêutico , Quimioterapia Combinada , Epoprostenol/análogos & derivados , Epoprostenol/uso terapêutico , Humanos , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/fisiopatologia , Masculino , Pessoa de Meia-Idade , Artéria Pulmonar/fisiopatologia , Tadalafila/uso terapêutico , Resultado do TratamentoRESUMO
BACKGROUND: Improving quality of life (QOL) has become an important goal in left ventricular assist device (LVAD) therapy. We aimed (1) to assess the effect of an implantable LVAD on patients' QOL, (2) to compare LVAD patients' QOL to that of patients in different stages of heart failure (HF), and (3) to identify factors associated with patients' QOL. METHODSâANDâRESULTS: The QOL of 33 Japanese implantable LVAD patients was assessed using the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and Short-form 8 (SF-8), before and at 3 and 6 months afterwards. After LVAD implantation, QOL significantly improved [MLHFQ, SF-8 physical component score (PCS), SF-8 mental component score (MCS), all P<0.05]. Implanted LVAD patients had a better QOL than extracorporeal LVAD patients (n=33, 32.1±21.9 vs. n=17, 47.6±18.2), and Stage D HF patients (n=32, 51.1±17.3), but the score was comparable to that of patients who had undergone a heart transplant (n=13). In multiple regression analyses, postoperative lower albumin concentration and right ventricular failure were independently associated with poorer PCS. Female sex and postoperative anxiety were 2 of the independent factors for poorer MCS (all P<0.05). CONCLUSIONS: Having an implantable LVAD improves patients' QOL, which is better than that of patients with an extracorporeal LVAD. Both clinical and psychological factors are influence QOL after LVAD implantation.
Assuntos
Insuficiência Cardíaca , Coração Auxiliar , Qualidade de Vida/psicologia , Inquéritos e Questionários , Adulto , Estudos Transversais , Feminino , Seguimentos , Insuficiência Cardíaca/psicologia , Insuficiência Cardíaca/cirurgia , Transplante de Coração , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores Sexuais , Disfunção Ventricular Direita/etiologia , Disfunção Ventricular Direita/psicologiaRESUMO
Although both beta-blocker treatment and cardiac resynchronization therapy (CRT) have been established as the standard therapeutic strategy to achieve left ventricular reverse remodeling (LVRR) and improve prognosis in heart failure (HF) patients with systolic LV dysfunction, some patients do not respond to such treatments. We here report a HF patient with left bundle branch block due to nonischemic cardiomyopathy who did not respond to 20 mg/day of carvedilol in terms of LVRR. Subsequent CRT only achieved insufficient LVRR, and we further titrated carvedilol up to 40 mg/day. Marked LVRR was accomplished at a fixed 70 bpm heart rate under CRT, and therefore it was considered as heart rate-independent. Up-titration of beta-blocker after CRT may be necessary to induce optimal LVRR in some populations.
Assuntos
Carbazóis/administração & dosagem , Terapia de Ressincronização Cardíaca/métodos , Cardiomiopatias/complicações , Insuficiência Cardíaca , Propanolaminas/administração & dosagem , Remodelação Ventricular/efeitos dos fármacos , Antagonistas Adrenérgicos beta/administração & dosagem , Bloqueio de Ramo/diagnóstico , Bloqueio de Ramo/etiologia , Bloqueio de Ramo/fisiopatologia , Bloqueio de Ramo/terapia , Carvedilol , Relação Dose-Resposta a Droga , Ecocardiografia , Eletrocardiografia , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Resultado do TratamentoRESUMO
Although endothelin receptor antagonists (ERAs) including bosentan and ambrisentan are essential tools for the treatment of pulmonary arterial hypertension (PAH), each agent has a specific adverse effect with non-negligible frequency, ie, liver dysfunction for bosentan and peripheral edema for ambrisentan. These adverse effects often hinder the titration of the doses of ERAs up to the therapeutic levels. Portopulmonary hypertension, which is complicated with liver cirrhosis and successive portal hypertension, is one of the PAHs refractory to general anti-PAH agents because of the underlying progressed liver dysfunction and poor systemic condition. We here present a patient with portopulmonary hypertension, which was treated safely by combination therapy that included low-dose bosentan and ambrisentan, minimizing the adverse effects of each ERA. Combination therapy including different types of ERAs at each optimal dose may become a breakthrough to overcome portopulmonary hypertension in the future.
Assuntos
Hemodinâmica/efeitos dos fármacos , Hipertensão Portal/tratamento farmacológico , Hipertensão Pulmonar/tratamento farmacológico , Cirrose Hepática/complicações , Fenilpropionatos , Piridazinas , Sulfonamidas , Anti-Hipertensivos/administração & dosagem , Anti-Hipertensivos/efeitos adversos , Bosentana , Terapia Combinada/métodos , Diagnóstico Diferencial , Relação Dose-Resposta a Droga , Ecocardiografia , Humanos , Hipertensão Portal/diagnóstico , Hipertensão Portal/etiologia , Hipertensão Portal/fisiopatologia , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/etiologia , Hipertensão Pulmonar/fisiopatologia , Masculino , Pessoa de Meia-Idade , Fenilpropionatos/administração & dosagem , Fenilpropionatos/efeitos adversos , Piridazinas/administração & dosagem , Piridazinas/efeitos adversos , Sulfonamidas/administração & dosagem , Sulfonamidas/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: Therapeutic strategies for pulmonary arterial hypertension (PAH) associated with atrial septal defect (ASD) remain a matter of debate. METHODS AND RESULTS: We identified 5 outpatients who had been diagnosed with ASD-PAH and undergone ASD closure in combination with targeted therapy with certified PAH drugs. We assessed changes in hemodynamic parameters and exercise capacity. The combination of ASD closure and targeted therapy significantly increased systemic blood flow (Qs) from the baseline (from 3.3 ± 0.6 L/minute to 4.2 ± 1.0 L/minute, P < 0.05) with a significant improvement in the World Health Organization Functional Class (WHO-FC; from 2.8 ± 0.4 to 1.6 ± 0.5, P < 0.05). The hemodynamic data before and after ASD closure without targeted therapy showed further elevation of pulmonary vascular resistance shortly after ASD closure (678 dyne · s/cm(5) to 926 dyne · s/cm(5)) in 1 case, as well as after a long time since ASD closure (491.0 ± 53.7 dyne · s/cm(5) to 1045.0 ± 217.8 dyne · s/cm(5)) in 2 cases. This worsening was reversed after the targeted therapy, accompanied by an increase in Qs and an improvement in WHO-FC in all cases. CONCLUSIONS: Targeted therapy should be added to ASD closure in adult patients with ASD-PAH.
Assuntos
Anti-Hipertensivos/administração & dosagem , Tolerância ao Exercício , Comunicação Interatrial , Hemodinâmica , Hipertensão Pulmonar , Complicações Pós-Operatórias , Adulto , Septo Interatrial/cirurgia , Bosentana , Cateterismo Cardíaco/métodos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/métodos , Gerenciamento Clínico , Epoprostenol/administração & dosagem , Epoprostenol/análogos & derivados , Feminino , Comunicação Interatrial/complicações , Comunicação Interatrial/fisiopatologia , Comunicação Interatrial/cirurgia , Humanos , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/tratamento farmacológico , Hipertensão Pulmonar/etiologia , Hipertensão Pulmonar/fisiopatologia , Japão , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/tratamento farmacológico , Complicações Pós-Operatórias/fisiopatologia , Estudos Retrospectivos , Sulfonamidas/administração & dosagem , Resultado do Tratamento , Resistência Vascular , Vasodilatadores/administração & dosagemRESUMO
Pulmonary hypertension (PH) induced by pulmonary tumor thrombotic microangiopathy (PTTM) can be fatal because its rapid progression confounds diagnosis, and it is difficult to control with therapy. Here we describe a woman with symptomatic PTTM-PH accompanying gastric cancer that was suspected from perfusion scintigraphy. PTTM-PH was diagnosed by gastroesophageal endoscopy and lung biopsy after partial control of PH using the platelet-derived growth factor (PDGF) receptor (PDGFR) tyrosine kinase inhibitor, imatinib. Treatment with sildenafil and ambrisentan further decreased PH, and she underwent total gastrectomy followed by adjuvant TS-1 chemotherapy. PH did not recur before her death from metastasis. Postmortem histopathology showed recanalized pulmonary arteries where the embolized cancer masses disappeared. PDGF-A, -B, and PDGFR-α, ß expression was detected in cancer cells and proliferating pulmonary vascular endothelial cells. Thus, PTTM-PH was successfully controlled using a combination of imatinib, drugs to treat pulmonary arterial hypertension, and cancer management.
Assuntos
Adenocarcinoma/secundário , Antineoplásicos/uso terapêutico , Benzamidas/uso terapêutico , Hipertensão Pulmonar/tratamento farmacológico , Neoplasias Pulmonares/secundário , Piperazinas/uso terapêutico , Pirimidinas/uso terapêutico , Receptores do Fator de Crescimento Derivado de Plaquetas/antagonistas & inibidores , Microangiopatias Trombóticas/tratamento farmacológico , Adenocarcinoma/terapia , Feminino , Humanos , Hipertensão Pulmonar/etiologia , Mesilato de Imatinib , Neoplasias Pulmonares/terapia , Pessoa de Meia-Idade , Neoplasias Gástricas/patologia , Neoplasias Gástricas/terapia , Microangiopatias Trombóticas/complicaçõesRESUMO
BACKGROUND: The continuous flow (CF) left ventricular assist device (LVAD) has replaced the pulsatile flow (PF) LVAD because of its advantages of better patient survival and higher quality of life. However, "late-onset right ventricular failure (RVF)" after CF LVAD implantation has emerged as an increasing concern, but little is known about the mechanism. METHODS AND RESULTS: We retrospectively analyzed the 3-month hemodynamic and echocardiographic data from 38 consecutive patients who had received CF LVADs, and from 22 patients who had received PF LVADs. Late-onset RVF was defined as persistent right ventricular stroke work index (RVSWI) <4.0g/m(2) at any rotation speed and after saline infusion test at 5 weeks after implantation of CF LVAD. Patients with late-onset RVF had significantly impaired exercise tolerance indicated by shorter 6-min walking distance and lower peak VO2, and worsened tricuspid regurgitation, together with enlargement of the RV under CF LVAD treatment (all P<0.05). Univariable analyses demonstrated that preoperative smaller LV diastolic diameter (LVDd) was the risk factor for late-onset RVF with a cutoff value of 64mm calculated by ROC analysis (area under curve, 0.925). In contrast, there was no correlation between preoperative LVDd and postoperative RVSWI in the PF LVAD group, though their preoperative background was worse than that of the CF group. CONCLUSIONS: In the setting of preoperative small LVDd, CF LVAD may cause late-onset RVF by leftward shift of the interventricular septum. (Circ J 2014; 78: 625-633).
Assuntos
Insuficiência Cardíaca/fisiopatologia , Ventrículos do Coração/fisiopatologia , Coração Auxiliar/efeitos adversos , Complicações Pós-Operatórias/fisiopatologia , Cuidados Pré-Operatórios/efeitos adversos , Disfunção Ventricular Direita/fisiopatologia , Adulto , Feminino , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Disfunção Ventricular Direita/epidemiologia , Disfunção Ventricular Direita/etiologiaRESUMO
BACKGROUND: The timing of ventricular assist device (VAD) implantation is always a matter of debate, especially when a patient is referred from a non-VAD institute. We focused on objective noninvasive parameters at the time of admission to a VAD implant center and analyzed the factors predicting the necessity of early VAD. METHODSâANDâRESULTS: We retrospectively analyzed advanced heart failure (HF) patients referred since January 2011, including patients less than 65 years old. They all had a history of hospitalization for HF management in non-VAD institutes within 1 month before referral. We excluded patients transferred with mechanical circulatory support. We enrolled 46 patients (40 males, 39.8±13.4 years old). Among them, 26 patients had a VAD implanted or died within 120 days. By multivariable logistic analysis using admission parameters, systolic blood pressure (BP) <93 mmHg [odds ratio (OR) 13.335], hemoglobin <12.7 g/dl (OR 12.175) and serum total cholesterol <144 mg/dl (OR 8.096) were significant predictors of early VAD requirement. We constructed a scoring system according to the ORs, and the area under the receiver-operating characteristic curve was 0.913. CONCLUSIONS: Low BP, low serum cholesterol and anemia on admission predict early VAD in advanced HF patients who have been treated in non-VAD institutes. Such patients should be promptly referred to a VAD implant center.
Assuntos
Anemia/epidemiologia , Colesterol/sangue , Insuficiência Cardíaca/terapia , Coração Auxiliar , Hipotensão/epidemiologia , Índice de Gravidade de Doença , Adulto , Antropometria , Área Sob a Curva , Fármacos Cardiovasculares/uso terapêutico , Terapia Combinada , Comorbidade , Feminino , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Coração Auxiliar/provisão & distribuição , Humanos , Japão , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Curva ROC , Encaminhamento e Consulta , Estudos Retrospectivos , Medição de Risco , Fatores de TempoRESUMO
Background:The timing of ventricular assist device (VAD) implantation is always a matter of debate, especially when a patient is referred from a non-VAD institute. We focused on objective noninvasive parameters at the time of admission to a VAD implant center and analyzed the factors predicting the necessity of early VAD.MethodsâandâResults:We retrospectively analyzed advanced heart failure (HF) patients referred since January 2011, including patients less than 65 years old. They all had a history of hospitalization for HF management in non-VAD institutes within 1 month before referral. We excluded patients transferred with mechanical circulatory support. We enrolled 46 patients (40 males, 39.8±13.4 years old). Among them, 26 patients had a VAD implanted or died within 120 days. By multivariable logistic analysis using admission parameters, systolic blood pressure (BP) <93 mmHg [odds ratio (OR) 13.335], hemoglobin <12.7 g/dl (OR 12.175) and serum total cholesterol <144 mg/dl (OR 8.096) were significant predictors of early VAD requirement. We constructed a scoring system according to the ORs, and the area under the receiver-operating characteristic curve was 0.913.Conclusions:Low BP, low serum cholesterol and anemia on admission predict early VAD in advanced HF patients who have been treated in non-VAD institutes. Such patients should be promptly referred to a VAD implant center.
RESUMO
To date, there have been few reports demonstrating preoperative predictors for left ventricular reverse remodeling (LVRR) after LV assist device (LVAD) implantation, especially among patients with dilated cardiomyopathy (DCM). We retrospectively analyzed 60 patients with stage D heart failure due to DCM who had received LVAD treatment [pulsatile flow (PF) type, 26; continuous flow type, 34]. Data were evaluated at 6 months or just before explantation of the LVAD. We defined "LV reverse remodeling" (LVRR) by the achievement of an LV ejection fraction (LVEF) of ≥ 35 % after 6 months of LVAD support or explantation of LVAD within 6 months. LVRR occurred in 16 of our patients (26.7 %). Uni/multivariate logistic regression analyses for LVRR demonstrated that of the preoperative variables evaluated, PF LVAD usage and insufficient preoperative ß-blocker treatment were independent predictors for LVRR. Patients who accomplished LVRR had a better clinical course, including lower levels of aortic valve insufficiency and lower levels of plasma B-type natriuretic peptide. Of the six patients (10.0 %) in whom LVADs were eventually explanted, all had an LVEF of ≥ 35 % before explantation or at 6 months. Based on these results, we conclude that DCM patients with insufficient preoperative ß-blocker treatment have a chance to achieve LVRR under LVAD support as a bridge to recovery.
Assuntos
Antagonistas Adrenérgicos beta/administração & dosagem , Cardiomiopatia Dilatada/tratamento farmacológico , Insuficiência Cardíaca/terapia , Coração Auxiliar , Remodelação Ventricular , Adulto , Cardiomiopatia Dilatada/complicações , Feminino , Insuficiência Cardíaca/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Fluxo Pulsátil , Estudos Retrospectivos , Adulto JovemRESUMO
Several studies have demonstrated that tolvaptan (TLV) can improve hyponatremia in advanced heart failure (HF) patients with rare chance of hypernatremia. However, changes in serum sodium concentrations (S-Na) in patients with or without hyponatremia during TLV treatment have not been analyzed.Ninety-seven in-hospital patients with decompensated HF who had received TLV at 3.75-15 mg/day for 1 week were enrolled. Among 68 "responders", who had achieved any increases in urine volume (UV) during the fi rst day, urinary sodium excretion during 24 hours (U-NaEx(24)) increased significantly during one week of TLV treatment along with higher baseline S-Na (P < 0.05 and r = 0.325). Considering a cut-off value (S-Na, 132 mEq/L; AUC, 0.711) for any increases in U-NaEx(24), we defined "hyponatremia" as S-Na < 132 mEq/L. In hyponatremic responders (n = 25), S-Na increased significantly, although 1 week was not sufficient for normalization (125.8 ± 5.0 versus 128.9 ± 4.3 mEq/L, P < 0.05), along with unchanged U-NaEx(24) (2767 ± 2703 versus 2972 ± 2950 mg/day, NS). In contrast, in normonatremic responders (n = 43), S-Na remained unchanged (136.6 ± 3.1 versus 137.4 ± 2.9 mEq/L, NS) along with increased U-NaEx(24) (2201 ± 1644 versus 4198 ± 3550 mg/day, P < 0.05). TLV increased S-Na only in hyponatremic responders by way of pure aquaresis, but increased U-NaEx(24) only in normonatremic responders, which explains the scarcity of hypernatremia. Epithelial Na-channels in the distal nephrons, whose repression by TLV increases urinary sodium excretion, may be attenuated by reduced ATP-supply in worse hemodynamics under hyponatremia.
Assuntos
Antagonistas dos Receptores de Hormônios Antidiuréticos , Benzazepinas/administração & dosagem , Insuficiência Cardíaca/tratamento farmacológico , Hipernatremia/sangue , Hiponatremia/sangue , Sódio/urina , Adulto , Diuréticos/administração & dosagem , Relação Dose-Resposta a Droga , Feminino , Seguimentos , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/metabolismo , Humanos , Hipernatremia/tratamento farmacológico , Hipernatremia/etiologia , Hiponatremia/tratamento farmacológico , Hiponatremia/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Sódio/sangue , Tolvaptan , Resultado do TratamentoRESUMO
Although survival after heart transplantation (HTx) has improved in recent years, cardiac allograft vasculopathy (CAV) is still the leading cause of remote morbidity and mortality in HTx recipients, partly because of difficulty with its diagnosis. In general, routine surveillance for CAV is advocated with coronary angiography accompanied by intravascular ultrasound (IVUS) if necessary. However, these modalities have limitations with respect to low spatial resolution, and sufficient qualitative/quantitative assessment of coronary intima has not been accomplished. Recently, optical coherence tomography (OCT) has emerged as a novel intracoronary imaging technique using an optical analogue of ultrasound with a spatial resolution of 10-20 µm, which is 10 times greater than IVUS. We here experienced a 49-year-old male who received a HTx 3 years ago, and OCT was executed during low molecular weight dextran injection. OCT demonstrated distinct double intimal layers probably consisting of a donor-transmitted atherosclerotic layer and an inner intimal proliferation due to CAV, which was indistinguishable by IVUS and virtual histological analyses. We believe that OCT imaging is not only a new loadstar during treatment of CAV but also a new generation modality for screening for early CAV in HTx recipients.
Assuntos
Aterosclerose/patologia , Cardiomiopatia Dilatada/cirurgia , Doença da Artéria Coronariana/patologia , Vasos Coronários/patologia , Transplante de Coração , Tomografia de Coerência Óptica/métodos , Túnica Íntima/patologia , Aloenxertos , Aterosclerose/diagnóstico por imagem , Doença da Artéria Coronariana/diagnóstico por imagem , Vasos Coronários/diagnóstico por imagem , Diagnóstico Diferencial , Humanos , Masculino , Pessoa de Meia-Idade , Doadores de Tecidos , Túnica Íntima/diagnóstico por imagem , Ultrassonografia de IntervençãoRESUMO
BACKGROUND: Urine osmolality (U-OSM) is valuable to predict response to tolvaptan (TLV) in decompensated heart failure patients, but measurement of U-OSM is not always available on site. METHODS AND RESULTS: Data were collected from 66 hospitalized patients with decompensated heart failure who had received TLV at 3.75-15 mg/day. U-OSM, which was estimated using the following formula: 1.07×{2×[(urine sodium (mEq/L)]+[urine urea nitrogen (mg/dl)]/2.8+[urine creatinine (mg/dl)]×2/3}+16, was well correlated with the actual measurement (r=0.938, P<0.001). Criteria consisting of C1 (estimated baseline U-OSM>358 mOsm/L) and C2 (%decrease in estimated U-OSM>24% at 4-6 h after the first TLV dose) significantly discriminated responders from non-responders (P<0.05). CONCLUSIONS: Response to TLV can be predicted using U-OSM, which can be estimated using urine urea nitrogen, sodium, and creatinine concentration data.
Assuntos
Antagonistas dos Receptores de Hormônios Antidiuréticos , Benzazepinas/uso terapêutico , Creatinina/urina , Insuficiência Cardíaca/tratamento farmacológico , Antagonistas de Hormônios/uso terapêutico , Nitrogênio/urina , Sódio/urina , Ureia/urina , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/urina , Distribuição de Qui-Quadrado , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/urina , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Biológicos , Concentração Osmolar , Estudos Retrospectivos , Fatores de Tempo , Tolvaptan , Resultado do TratamentoRESUMO
BACKGROUND: A newly-developed vasopressin type 2 receptor antagonist, tolvaptan (TLV), has a unique feature of diuresis, but the response to this drug can be unpredictable. METHODS AND RESULTS: Data were collected from hospitalized patients with decompensated congestive heart failure who were administered TLV at 3.75-15 mg/day (n=61). A responder/non-responder to TLV was determined as having any increase/decrease in urine volume (UV) during the next 24h after TLV treatment on the first day. Logistic regression analyses for increases in UV were performed, and independent predictors of the responder were the following: C1, baseline urine osmolality (U-OSM) >352 mOsm/L; and C2, %decrease in U-OSM >26% at 4-6h after TLV administration. Criteria consisting of C1 and C2 had a good predictability for responders by receiver-operating characteristic analysis (area under the curve=0.960). Kidneys of the non-responders no longer had diluting ability (%decrease of U-OSM at 4-6h=2.7 ± 14.6%*), but also barely kept concentrating ability (baseline U-OSM=296.4 ± 68.7*mOsm/L) with markedly reduced estimated glomerular filtration ratio (35.5 ± 29.4 m l · min(-1) · 1.73 m(-2)*) (*P<0.05 vs. patients who had at least 1 positive condition [n=42]). CONCLUSIONS: More than 26% decrease in U-OSM from a baseline >352 mOsm/L for the first 4-6h predicts responders to TLV. Unresponsiveness to TLV is attributable to nephrogenic diabetes insipidus complicated by chronic renal disease.
Assuntos
Antagonistas dos Receptores de Hormônios Antidiuréticos , Benzazepinas/uso terapêutico , Diabetes Insípido Nefrogênico/urina , Monitoramento de Medicamentos/métodos , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/urina , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Nitrogênio da Ureia Sanguínea , Creatina/sangue , Creatina/urina , Diabetes Insípido Nefrogênico/tratamento farmacológico , Diuréticos/administração & dosagem , Feminino , Insuficiência Cardíaca/diagnóstico por imagem , Humanos , Hipovolemia/tratamento farmacológico , Hipovolemia/urina , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Concentração Osmolar , Potássio/sangue , Potássio/urina , Valor Preditivo dos Testes , Insuficiência Renal Crônica/tratamento farmacológico , Insuficiência Renal Crônica/urina , Sensibilidade e Especificidade , Sódio/sangue , Sódio/urina , Tolvaptan , Ultrassonografia , Urina , Adulto JovemRESUMO
BACKGROUND: The aim of this study was to examine trends of clinical outcome and to clarify surrogate markers when titrating ß-blocker in heart failure patients with reduced left ventricular ejection fraction (HFrEF, LVEF <50%). METHODS AND RESULTS: Consecutive HFrEF patients starting on ß-blocker were divided into 2 groups according to time of dose fixation attainment: before 31 December 2005 (group 1, n=108) or after 1 January 2006 (group 2, n=119). There were no significant differences in patient characteristics between the 2 groups at baseline. Beta-blocker fixed dose was higher with lower resting heart rate in group 2 (6.2±5.7mg/day vs. 9.5±9.1mg/day in carvedilol equivalent dose, P=0.001; 74.2±11.1beats/min vs. 70.2±9.7beats/min, P=0.004). The rate of HF hospitalization and/or all-cause death after 36 months was lower in group 2 than in group 1 (22% vs. 38%, P=0.011; hazard ratio, 0.90; P=0.012). Cox regression analysis showed that ß-blocker ≥10mg/day and achieved heart rate ≤71beats/min predicted a better outcome (both P<0.05). CONCLUSIONS: Recent improvement of clinical outcome among HFrEF patients may be attributable to the up-titration policy accompanying lowered heart rate. Resting heart rate ≤71beats/min and ß-blocker ≥10mg/day (ie, 50% of the target dose for Japanese patients) could be surrogate markers when titrating ß-blocker.
Assuntos
Antagonistas de Receptores Adrenérgicos alfa 1/farmacologia , Carbazóis/farmacologia , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/fisiopatologia , Frequência Cardíaca/efeitos dos fármacos , Propanolaminas/farmacologia , Volume Sistólico/efeitos dos fármacos , Idoso , Biomarcadores , Carvedilol , Relação Dose-Resposta a Droga , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
No medical treatment has been established to ameliorate pulmonary hypertension (PH) due to left heart disease. Heart transplantation (HTx) is thus far the definitive therapy for stage D heart failure, but concomitant PH is one of the major risk factors for death after HTx. Recently, implantation of a left ventricular assist device (LVAD) has been reported to improve PH and has become a major bridge tool for HTx. We experienced a rare case with persistent PH even after the implantation of a continuous-flow LVAD. The administration of an endothelin receptor antagonist, bosentan, significantly decreased pulmonary vascular resistance. Combination therapy with LVAD implantation and anti-PH medication may be useful for patients with stage D heart failure complicated with severe PH.
Assuntos
Anti-Hipertensivos/uso terapêutico , Insuficiência Cardíaca/cirurgia , Transplante de Coração , Coração Auxiliar , Hipertensão Pulmonar/tratamento farmacológico , Sulfonamidas/uso terapêutico , Bosentana , Insuficiência Cardíaca/complicações , Humanos , Hipertensão Pulmonar/etiologia , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
There has been no established medical therapy to ameliorate pulmonary hypertension (PH) owing to left heart disease (LHD-PH). It has recently been shown that the left ventricular assist device (LVAD) can improve LHD-PH and therefore has the potential to become a major bridge tool for heart transplantation (HTx). However, some patients still have persistent PH even after LVAD treatment. It is essential to demonstrate the reversibility of end-organ dysfunction, including PH, prior to implantable LVAD treatment, especially in Japan, because implantable LVAD treatment is indicated only as bridge to transplantation. Here we report a patient with LHD-PH whose PH was demonstrated to be reversible by the acute pulmonary vasoreactivity test (APVT) with nitrogen monoxide (NO) and the phosphodiesterase-5 inhibitor sildenafil. Both inhaled NO and sildenafil reduced pulmonary vascular resistance, but pulmonary capillary wedge pressure was increased by NO, which was conversely decreased under increased cardiac output by sildenafil. After the patient was listed as an HTx recipient, pulmonary vascular resistance recovered down to an acceptable range with LVAD treatment. Based on these findings, we suggest that the APVT with sildenafil may be a useful and safe tool to predict improvement of PH after LVAD treatment.
Assuntos
Cardiomiopatia Dilatada/cirurgia , Insuficiência Cardíaca/cirurgia , Hipertensão Pulmonar/fisiopatologia , Óxido Nítrico , Piperazinas , Sulfonas , Adulto , Cardiomiopatia Dilatada/fisiopatologia , Insuficiência Cardíaca/fisiopatologia , Transplante de Coração , Coração Auxiliar , Humanos , Hipertensão Pulmonar/diagnóstico , Masculino , Implantação de Prótese , Purinas , Citrato de SildenafilaRESUMO
We previously defined "responders" as patients with increases in urine volume (UV) on day 1 after the administration of tolvaptan (TLV), and demonstrated that responders to TLV could be predicted with considerable accuracy by urine osmolality (U-OSM) levels. Responders and non-responders to TLV should be associated with different clinical courses after a certain time following TLV administration. Therefore, the aim of the present study was to validate our definition of responders by clinical parameters 1 week after administration of TLV. Data (n = 85) were obtained from in hospital patients with decompensated heart failure (HF) who had received TLV at 3.75-15 mg daily, and clinical data at 1 week after the administration of TLV were compared with those of baseline. Sixty patients (70.6%) were "responders", in whom UV on day 1 increased after the administration of TLV compared with day 0. "Non-responders" were older, and had higher serum creatinine concentration and lower baseline U-OSM than "responders". Serum creatinine concentration increased significantly in "non-responders", but was unchanged in "responders". Body weight, plasma B-type natriuretic peptide concentration, and HF symptom score decreased significantly in "responders", but remained unchanged in "non-responders". Increases in UV after the first administration of TLV were closely correlated with improvement of congestive HF after 1 week of TLV treatment, which verified our definition of "responders" to TLV.
Assuntos
Antagonistas dos Receptores de Hormônios Antidiuréticos , Benzazepinas/uso terapêutico , Diuréticos/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Tolvaptan , Urina , Adulto JovemRESUMO
The long-term survival of heart transplantation (HTx) recipients has increased significantly in recent years, however, the nephrotoxic adverse effects of calcineurin inhibitors (CNIs) are still a major concern. Recently, an inhibitor of mammalian target of rapamycin, everolimus (EVL), has emerged as an alternative immunosuppressant drug that may allow CNI dosage reduction and thereby spare renal function. Data were collected from 20 HTx recipients who had received EVL (target trough level 3-8 ng/mL) along with a dose reduction of CNIs and/or mycophenolate mophetil (MMF) and had been followed for 1 year. Estimated glomerular filtration rate increased significantly with a reduction in the CNI dosage in a dose-dependent manner (P < 0.001, r = -0.807). Neutrophil count increased significantly (P < 0.05) with a reduction in the dosage of MMF (P = 0.009, r = -0.671). Cytomegalovirus antigenemia remained negative after EVL administration among all candidates without any antiviral agents (P = 0.001). There were no significant increases in the acute rejection rates among recipients with EVL compared to those without EVL (P = 0.132). An immunosuppressant strategy incorporating EVL could reduce the CNI and MMF dosages, which resulted in improvements in renal dysfunction and neutropenia while maintaining low rejection rates among HTx recipients.
Assuntos
Taxa de Filtração Glomerular/efeitos dos fármacos , Rejeição de Enxerto/epidemiologia , Transplante de Coração/mortalidade , Imunossupressores/administração & dosagem , Guias de Prática Clínica como Assunto , Insuficiência Renal/prevenção & controle , Sirolimo/análogos & derivados , Adolescente , Adulto , Antineoplásicos , Criança , Relação Dose-Resposta a Droga , Everolimo , Feminino , Seguimentos , Rejeição de Enxerto/tratamento farmacológico , Humanos , Imunossupressores/uso terapêutico , Incidência , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Ácido Micofenólico/administração & dosagem , Ácido Micofenólico/análogos & derivados , Ácido Micofenólico/uso terapêutico , Insuficiência Renal/etiologia , Insuficiência Renal/fisiopatologia , Estudos Retrospectivos , Sirolimo/administração & dosagem , Sirolimo/uso terapêutico , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
Chronic kidney disease (CKD) is often complicated with advanced heart failure because of not only renal congestion and decreased renal perfusion but also prolonged use of diuretics at higher doses, which sometimes results in hyponatremia. Preoperative CKD is known to be associated with poor prognosis after heart transplantation (HTx). We experienced a stage D heart failure patient with CKD and hyponatremia who was switched from trichlormethiazide to tolvaptan. His hyponatremia was normalized, and his renal function was improved after conversion to tolvaptan. In patients with stage D heart failure, it may be useful to administer tolvaptan with a concomitant reduction in the dose of diuretics in order to preserve renal function and avoid hyponatremia before HTx.