Heart failure with complete recovery in a patient with systemic lupus erythematosus

We report the case of a 43-year-old female patient who was admitted to the Cardiology Department from the Rheumatology Clinic where she was being treated for multi-organ serositis, fatigue and mild dyspnoea on exertion. The patient had a known medical history of systemic lupus erythematosus (SLE). Following extensive evaluation with blood tests for immunological and viral culprits, cardiac ultrasound, chest and abdominal computed tomography (CT) and heart magnetic resonance imaging (MRI), the diagnosis of effusive constrictive pericarditis secondary to her SLE was made. Treatment with β-blockers, diuretics and corticosteroids was given with excellent results, and one year post discharge the patient remains asymptomatic. Systemic lupus erythematosus patients often manifest cardiac complications such as pericarditis. The practising physician should always bear in mind this possibility when treating such patients.     

Age and heart transplantation: results from a heart failure management unit

Abstract: Background: More evidence is needed to assess the pros and cons of maintaining age‐limit policies in heart transplantation (HT). Methods: We analyzed clinical data from a heart failure management unit to investigate the impact of age on prognosis of two distinct cohorts: (i) 309 patients (median age, 57 yr; 62% male) with severe chronic heart failure (CHF) consecutively screened for HT; (ii) 336 HT recipients (median age 56 yr, 82% male). Results: In CHF patients (screened for HT), prognosis was conditioned by the underlying severity of cardiac disease (i.e., New York Heart Association class III–IV, decreasing blood pressure, presence of atrial fibrillation and severe mitral regurgitation), whereas increasing age showed no sign of predicting all‐cause or cardiovascular mortality (both p ≥ 0.4). In HT recipients, age did not retain significance at multivariate analysis as an independent predictor (p ≥ 0.14 for both all‐cause and cardiovascular death), whereas ischemic etiology of pre‐existing CHF did (p ≤ 0.02). Conclusions: Age did not appear to be a primary determinant of all‐cause or cardiovascular mortality among potential HT candidates or eventual recipients (ischemic etiology of CHF turned out to be the major determinant of post‐transplant outcome). These results support the concept that HT may be considered a treatment option in patients with more advanced age strata, particularly when affected by non‐ischemic cardiomyopathy.     

Girdling effect of adynamic cardiomyoplasty in a model of dilated cardiomyopathy

OBJECTIVE: The potential benefits of adynamic cardiomyoplasty remain unclear. We determined whether unstimulated skeletal muscle wrap alone prevents or attenuates progressive left ventricular dilation in a canine model of congestive heart failure produced by repeated intracoronary infusions of doxorubicin. SUBJECTS AND METHODS: 14 dogs were randomized in to 2 groups, 1 undergoing cardiomyoplasty (CMP group) and 1 that did not (CONT group). Intracoronary doxorubicin was administered weekly for 5 weeks to induce heart failure. Hemodynamic data was obtained before infusion and 5 weeks afterward. Echocardiography was done weekly. RESULTS: Significant left ventricular dilation was observed in the CONT group--left ventricular end-diastolic diameter increased from 28.9 +/- 2.7 to 38.5 +/- 3.3 mm (p < 0.05). Significant left ventricular dilation was also observed in the CMP group--left ventricular end-diastolic diameter increased from 28.9 +/- 3.3 to 38.0 +/- 4.2 mm (p < 0.05). Dilation was slower in the CMP group than in the CONT group, however. Ejection fraction decreased from 58.0 +/- 13.8 to 29.9 +/- 13.7% in the CONT group, but was preserved from 56.0 +/- 8.8 to 51.9 +/- 10.3% in the CMP group. CONCLUSIONS: Adynamic cardiomyoplasty reduces ventricular dilation associated with heart failure without exacerbating left ventricular dysfunction.     

Atrial natriuretic peptide as a preload depressor in acute renal failure secondary to congestive heart failure

The present study was undertaken to verdy the hypothesis that infusion of atrial natriuretic peptide (ANP) might lower preload and be beneficial in the treatment of pulmonary congestion even without a diuresis in patients with acute renal failure (ARF) secondary to severe congestive heart failure (CHF). We studied 22 patients with ARF secondary to CHF. The mean age of the patients (14 men and 8 women) was 72 years (range 36 to 85 years). Seven of the patients had dilated cardiomyopathy, ten had ischemic heart disease, and five had valvular heart disease. ANP was infused intravenously and the following data before and 1 hour after the start of ANP infusion were recorded; urinary output, systemic blood pressure (SBP), pulmonary blood pressure (PBP), right atrial pressure (RAP), cardiac index (CI), heart rate (HR), and arterial blood oxygen pressure. Diastolic PBP were employed as plumonary capillary wedge pressure. Urinary output did not change. Mean SBP decreased from 92 to 85 mmHg (p < 0.05), and mean PBP decreased from 34 to 28 mmHg (p < 0.01). Mean RAP decreased from 11 to 9 mmHg (p < 0.01) and diastolic PBP decreased from 25 to 19 mmHg (p < 0.01). HR did not change significantly and CI increased 2.4 to 2.5 mi/min/m² (p < 0.05). Arterial blood oxygen partial pressure increased significantly from 71 to 82 mmHg (p < 0.05). In conclusion, ANP decreased and improved arterial blood oxygen partial prissure, though diuretic response to ANP is attenuated in ARF secondary to CHE. Infusion of ANP will be very beneficial in cases in which dyspnea and pulmonary edema due to elevation of preload are the principal clinical problems.     

Can heat therapy help patients with heart failure?

To review and analyze the clinical outcomes of thermal therapy (≤1.4°C increase in core body temperature) in patients with heart failure (HF). A systematic review and meta-analysis regarding the effects of thermal therapy on HF was done by searching PubMed, Ovid Medline, Ovid Embase, Scopus, and internal databases up to date (2019).

• Improvement in the New York Heart Association (NYHA) class : Ten studies with 310 patients showed significant improvement in NYHA class. Only 7 among 40 patients remained in Class IV and 99 patients in Class III from 155 patients. Increased patients in lower classes indicate that more patients showed improvement. Sixteen studies on 506 patients showed an overall improvement of 4.4% of left ventricular ejection fraction (LVEF). Four studies reported improved endothelial dysfunction by 1.7% increase in flow-mediated dilation (FMD) on 130 patients.
• Reduction in blood pressure: Thermal therapy reduced both systolic blood pressure (SBP) and diastolic blood pressure by 3.1% and 5.31%, respectively, in 431 patients of 15 studies.
• Decrease in cardiothoracic ratio (CTR): Eight studies reported an average of 5.55% reduction of CTR in a total of 347 patients.
• Improvement in oxidative stress markers: Plasma brain natriuretic peptide (BNP) levels significantly decreased (mean difference of 14.8 pg/dL) in 303 patients of 9 studies.
• Improvement of quality of life: Among 65 patients, thermal therapy reduced cardiac death and rehospitalization by 31.3%.

A slight increase in core body temperature is a promising, noninvasive, effective, and complementary therapy for patients with HF. Further clinical studies are recommended.     

Long-term discontinuation of warfarin in a patient with HeartMate 3 left ventricular assist device without complication

A 38-year-old woman with peripartum cardiomyopathy underwent placement of a HeartMate 3 (HM3) left ventricular assist device (LVAD). Postoperatively, she refused warfarin therapy and was maintained on aspirin monotherapy for 19 months. She did not experience thrombotic or thromboembolic complications associated with lack of oral vitamin K antagonist anticoagulation. Our patient represents the longest reported duration of a patient with HM3 LVAD maintained without warfarin without evidence of thrombotic or thromboembolic events.     

Successful management of a giant spinal arteriovenous malformation with multiple communications between primitive arterial and venous structures by embolization: Report of a case

A 47-year-old woman was admitted to our hospital with a giant spinal arteriovenous malformation (AVM) causing heart failure and thoracic myelopathy. Angiography revealed that the spinal AVM had multiple feeding vessels branching from the 5th through 12th intercostal arteries. The drainage vein flowed to the azygos vein and superior vena cava. The AVM destroyed the 7th thoracic vertebra. The cardiac output was 16.7l/min and the shunt ratio was 64% before treatment. Embolization with cyanoacrylate was performed because the operation was considered to be associated with a significant risk of paraplegia and organ ischemia. The cardiac output decreased to 11.6l/min and the shunt ratio was reduced to 32%. After embolization the patient demonstrated no symptoms of either heart failure or sensory deficits. During embolization, provocative tests using sodium amytal and lidocaine with magnetic stimulation were also performed. The above findings suggest that provocative tests and magnetic stimulation are useful to predict paraplegia, which could result from embolization while, in addition, embolization is considered to be a useful treatment for multiple shunt and nidus in this region.     

High-Output Heart Failure Caused by a Huge Renal Arteriovenous Fistula After Nephrectomy: Report of a Case

Postnephrectomy renal arteriovenous fistula (AVF) with an aneurysmal lesion is a rare clinical entity that may cause high-output heart failure. In this report, we describe the case of a 68-year-old man who had undergone nephrectomy for renal tuberculosis 43 years previously, in whom an acquired large renal AVF presenting as an aneurysm caused congestive cardiac failure. We also discuss the hemodynamic, hormonogenic (human arterial natriuretic polypeptide; hANP), and radiographic findings before and after surgery for the AVF. The AVF with an aneurysmal lesion was clearly visualized by three-dimensional-computerized tomographic (CT) scanning, and proximal ligation of the renal artery was followed by an uneventful recovery. This procedure can produce good results when a fistula is too large to allow safe embolization and when excision would be hazardous due to inflammation surrounding the fistula. Received: March 1, 2000 / Accepted: November 20, 2000     

Soluble Klotho Protects against Uremic Cardiomyopathy Independently of Fibroblast Growth Factor 23 and Phosphate

Cardiac hypertrophy occurs in up to 95% of patients with CKD and increases their risk for cardiovascular death. In the kidney, full-length membranous Klotho forms the coreceptor for fibroblast growth factor 23 (FGF23) to regulate phosphate metabolism. The prevailing view is that the decreased level of Klotho in CKD causes cardiomyopathy through increases in serum FGF23 and/or phosphate levels. However, we reported recently that soluble Klotho protects against cardiac hypertrophy by inhibiting abnormal calcium signaling in the heart. Here, we tested whether this protective effect requires changes in FGF23 and/or phosphate levels. Heterozygous Klotho-deficient CKD mice exhibited aggravated cardiac hypertrophy compared with wild-type CKD mice. Cardiac magnetic resonance imaging studies revealed that Klotho-deficient CKD hearts had worse functional impairment than wild-type CKD hearts. Normalization of serum phosphate and FGF23 levels by dietary phosphate restriction did not abrogate the aggravated cardiac hypertrophy observed in Klotho-deficient CKD mice. Circulating levels of the cleaved soluble ectodomain of Klotho were lower in wild-type CKD mice than in control mice and even lower in Klotho-deficient CKD mice. Intravenous delivery of a transgene encoding soluble Klotho ameliorated cardiac hypertrophy in Klotho-deficient CKD mice. These results suggest that the decreased level of circulating soluble Klotho in CKD is an important cause of uremic cardiomyopathy independent of FGF23 and phosphate, opening new avenues for treatment of this disease.     

A UK Single Centre Retrospective Analysis of the Relationship between Haemodynamic Changes and Outcome in Patients Undergoing Prolonged Left Ventricular Assist Device Support

Purpose: Despite their efficacy, LVADs remain associated with serious complications. The relationship between haemodynamic changes during support and outcome remains inadequately characterised. This association was investigated in LVAD recipients undergoing prolonged support.Methods: Forty patients receiving LVAD therapy for >2 years were reviewed retrospectively (mean support duration was 38.62 ± 15.28). Pre- and on-LVAD haemodynamic data were assessed in three groups: (1) those receiving ongoing support (n = 24); (2) those who underwent cardiac transplantation (n = 4); (3) those who died during support (n = 12).Results: For group 1 and 2, LVAD support achieved a decrease in mean PAP, mean PCWP, TPG, and PVR and an increase in thermodilution blood flow (TBF) with significance at ≤5% level. For group 3, there were non-significant changes in TPG and PVR at the 5% level but for mean PAP, mean PCWP, and TBF the changes were similar to Groups 1 and 2 with significance at ≤5% level. Aggregated data from all three groups showed a 58% increase in TBF on LVAD support.Conclusion: Highly significant and favourable haemodynamic changes were found. However, group 3 did not undergo decrease in TPG and PVR possibly because of suboptimal LVAD flow, right heart dysfunction and unavoidable prolongation of support.     

Drugs acting on the heart: heart failure and coronary insufficiency

Heart failure (HF) and coronary insufficiency are common amongst surgical and critical care patients. Both are chronic conditions interrupted by acute episodes. HF activates neurohormonal mechanisms that worsen renal and cardiac function. Acute heart failure (AHF) commonly presents with dyspnoea as a consequence of systolic and/or diastolic dysfunction. Goals of treatment are symptom relief, to maintain tissue perfusion and optimize cardiac function. Diuretics and vasodilators are used early; positive inotropic drugs are reserved for when other treatment has failed. Chronic heart failure (CHF) is treated using changes in lifestyle and drugs to manage symptoms. ACE inhibitors and beta-blockers are effective in systolic heart failure and are associated with improved mortality. HF with preserved ejection fraction (HFPEF) is less responsive to drug therapy, though outcomes are better than for systolic HF. Coronary insufficiency occurs because of an imbalance of myocardial oxygen balance, leading to symptoms of ischaemic heart disease (IHD). Treatment goals are maintaining coronary blood flow and reducing myocardial oxygen demand. Beta-blockers and anti-platelet drugs improve outcomes; modern anti-platelets are more effective but are associated with risks of haemorrhage. Statins are effective for primary and secondary prevention of myocardial infarction; they have additional anti-inflammatory properties.     

A catheter based chronic porcine model of post-infarct dilated heart failure

Objectives. New surgical treatments for post-infarct antero-septal myocardial akinesia have been developed but evaluation of their mode of function is hampered by absence of suitable large animal heart failure models. We aimed to develop and evaluate a human compatible model for chronic post-infarct left ventricular (LV) remodeling. Design. Fourteen female 50 kg pigs underwent catheter-based coronary artery occlusion (one hour) distal to the first LAD diagonal. Eight weight- and age-matched healthy animals served as controls. LV geometry and function were assessed after 6 weeks with cardiovascular MRI. Results. All animals recovered from interventions. Three animals died during follow-up. All intervention animals had antero-septal akinetic infarcts (mean 26.5% of LV myocardium). Intervention animals had significantly increased end-diastolic and end-systolic volumes, and decreased stroke volume, ejection fraction and cardiac output. Detailed functional analysis showed significant systolic- and diastolic-dysfunction in intervention animals. Conclusions. We have established a feasible model of post-infarct LV remodeling, which accurately simulates human pathogenesis and pathophysiology. The model may be suitable for evaluation of novel surgical alleviations for heart failure.     

Longitudinal evaluation of ventricular ejection fraction and NT-proBNP across heart failure subgroups

Objectives: Left ventricular ejection fraction (EF) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are important surrogate markers of cardiac function and wall stress. Randomized trials of heart failure (HF) have shown improvements in survival in patients with reduced EF (<40%, HFrEF) but not with preserved EF (≥50%, HFpEF) or mid-range EF (40-49%, HFmrEF). Limited information is available on the trajectory of EF in contemporary heart failure management programs (HFMPs).

Design: 201 HF patients consecutively enrolled 2010–2011 in the outpatient-based HFMP of Skåne University Hospital in Lund were included in the study. Probable etiology, EF, NT-proBNP and medications were assessed at baseline and 1 year after enrollment.

Results: HFrEF was the most common heart failure subgroup (78.1% of patients) in this HFMP, followed by HFmrEF (14.9%) and HFpEF (7.0%). The most common etiology was ischemic heart disease (IHD, 40.8%).

Complete recovery of EF (>50%) was rare (14.1% of patients with HFrEF and 26.7% with HFmrEF), some degree of improvement was observed in 57.7% and 46.7% of patients. LVEF improved on average 9.1% in patients with HFrEF (p?p?Conclusions: This study provides estimates of the improvement in LVEF and NT-proBNP that can be expected with contemporary management across subgroups of HF and different etiologies in a contemporary HFMP.     

黄芪注射液治疗慢性肾衰竭合并心力衰竭的临床疗效

目的:观察黄芪注射液治疗慢性肾衰竭合并心力衰竭的疗效。方法:将60例慢性肾衰合并心力衰竭病人分为两组。对照组30例予西医治疗。治疗组30例在西医治疗基础上加用黄芪注射液30 ml溶入10％G.S 250 ml中静脉滴注,qd连用10 d。结果:治疗组心功能明显改善,总有效率90％,明显高于对照组(P<0.05);治疗组左室射血分数(LVEF)和左室短轴缩短率(ΔD％)均显著提高(P<0.05)。结论:黄芪注射液能明显改善慢性肾衰病人的心功能。     

Ligation of ameroid-stenosed coronary artery leads to reproducible myocardial infarction--a pilot study in a porcine model

OBJECTIVE: Myocardial gene and cellular therapies have revived the use of porcine ischemic heart models. Commonly applied ameroid-obstruction produces inconsistent coronary stenoses and myocardial lesions, whereas abrupt coronary occlusion causes arrhythmias and sudden death. To produce a constant myocardial lesion after adaptation to ischemia, we surgically modified the ameroid-model by ligation. As a pilot study for further cell therapy research, the spontaneous myocardial response is described. MATERIALS AND METHODS: Simultaneously with ameroid application, a loose loop of nonabsorbable thread was placed around the left circumflex artery (LCx) on 11 domestic piglets. Three weeks later, the loop was tightened. Coronary arteriograms with Rentrop collateral grading from 0 to 3, and 99mTc-single photon emission computerized tomography studies were performed 1 to 5 wk after ligation. At autopsy, the hearts were analyzed macroscopically, histologically, and with von Willebrandt factor-staining. RESULTS: LCx-banding was well-tolerated in nine animals, of which angiographic occlusion was gained in eight. Postmortem analysis revealed a 5 to 10 cm(2) transmural or subendocardial lateral myocardial infarction in all except one heart. One week after occlusion, LCx showed well-developed collateral filling (Rentrop-grade 2.7 +/- 0.4), which remained unchanged at 5 wk. On single photon emission computerized tomography-scans, lateral wall perfusion increased spontaneously between 1 and 5 wk (P = 0.02), and von Willebrandt factor revealed clusters of neovascularization at the borders of infarct areas. CONCLUSIONS: This new modification of ameroid model standardizes myocardial lesion, which might reduce animal number in preclinical studies, thus having ethical aspect. The remarked potential for spontaneous recovery in ischemic porcine myocardium should be considered in preclinical therapeutic studies.