Impact of preoperative atrial fibrillation in patients with left ventricular assist device: A systematic review and meta‐analysis

Atrial fibrillation (AF) is a common finding in patients evaluated for left ventricular assist device (LVAD). There is conflicting data regarding the mortality risk as well as the thromboembolic risk in patients with preoperative AF who undergo LVAD implantation. We examined these risks by performing a meta‐analysis. We performed a literature search of Pubmed, EMBASE, SCOPUS, and Cochrane from inception to February 2018. The eligible studies were used to compare mortality rate and thromboembolic risk between AF and Non‐AF (NAF) groups after LVAD implantation. We obtained 391 articles from our search strategy. Seven retrospective studies were included and accounted for 5823 LVAD patients (AF 1589; NAF 4234). The median follow‐up duration ranged from 7–24 months. The pooled analysis revealed a significantly increased risk of mortality in preoperative AF patients who underwent LVAD operation compared to those with NAF (Risk Ratio [RR] 1.16, 95% CI 1.05‐1.28, I2 = 0%). Five studies reported thromboembolism events involving 1359 preoperative AF and 3893 NAF patients. The pooled analysis did not show a statistically significant association between risk of thromboembolic event and preoperative AF (Risk Ratio [RR] 1.08, 95% CI 0.86‐1.36, I2 = 76.2%). Our study shows that preoperative AF may be associated with a higher mortality rate. This study is limited by the fact that the data are pooled from retrospective studies. Further prospective studies are warranted in order to validate these results.     

Meta-analysis of vitamin D supplementation in the treatment of chronic heart failure

Objectives. We performed a meta-analysis to determine whether vitamin D supplementation is beneficial in patients with chronic heart failure (CHF). Design. Meta-analysis of randomised controlled trials. Results. Vitamin D supplementation in patients with CHF improved health-related quality of life and C-reactive protein levels [weighted mean difference (WMD): 6.75, 95% confidence interval (CI): 2.87 to 10.64, p?p?=?.007]. However, this supplementation was not superior to conventional treatment in terms of mortality, changes in left ventricular ejection fraction (ΔLVEF), N-terminal pro-B-type natriuretic peptide or B-type natriuretic peptide levels, and 6-minute walk distance (risk ratio: 1.11, 95% CI: 0.79 to 1.57, p?=?.53; WMD: 2.56, 95% CI: ?2.18 to 7.31, p?=?.29; SMD: ?0.18, 95% CI: ?0.42 to 0.06, p?=?.15; WMD: ?23.30, 95% CI: ?58.31 to 11.72, p?=?.19). In contrast, ΔLVEF significantly improved (WMD: 6.75, 95% CI: 4.16 to 9.34, p?Conclusions. Vitamin D supplementation decreases serum levels of inflammatory markers and improves quality of life in CHF patients. Pooled analysis of vitamin D supplementation did not show reduced mortality or improved left ventricular function perhaps because of excessive increase in plasma 25-hydroxyvitamin D and calcium levels. Future studies should pay attention to vitamin D and calcium levels achieved.     

Left ventricular geometry and cardiovascular mortality based on haemodialysis patient autopsy analyses

Aim: In end‐stage renal disease (ESRD) patients, left ventricular hypertrophy (LVH) is common and a risk for cardiovascular events. LVH is geometrically classified into two major groups, concentric and eccentric, and accumulating evidence suggests eccentric LVH has a more negative effect than concentric LVH on ESRD outcome. However, there have been very few studies on the cardiac findings from ESRD patient autopsy in which the relationship between LVH geometry and mortality was analyzed. Methods: An observational study was performed with the autopsy findings in 30 haemodialysis patient cases between 2001 and 2006 at Mitsui Memorial Hospital, Tokyo. Between those who died of a cardiovascular cause and those who died of non‐cardiovascular causes, we compared the heart/bodyweight ratio, left ventricular dilatation, and the extent of fibrosis of the left ventricle. Results: Heart/bodyweight ratio was significantly higher (P < 0.0001) in the cardiovascular mortality group (n = 11, 11.7 ± 2.5 g/kg) compared to the non‐cardiac cause of death group (n = 19, 8.05 ± 0.7 g/kg). The dilatation of the left ventricle was significantly more frequent in the cardiovascular than the non‐cardiac cause of death group (P = 0.016). Additionally, the fibrotic area of left ventricular cross‐section was larger in the cardiovascular (1.63 ± 1.6%) than the non‐cardiac group (0.83 ± 1.7%, P = 0.04). Conclusion: This autopsy study indicates that eccentric LVH in haemodialysis patients is closely associated with cardiovascular mortality. LVH geometry, as well as LVH severity, is worthy of consideration as a clinical predictor for cardiovascular mortality.     

Surgery for Chronic Left Ventricular Aneurysm: Benefits and side effects

Seventy patients who underwent elective resection of symptomatic postinfarction apico-anterior left ventricular (LV) aneurysm with or without coronary revascularization are reviewed. The early (?30 day) mortality was 5.7%. Mural thrombosis occurred in 29 cases (41.4%), unrelated to the degree of preoperative LV impairment and predictable from preoperative LV angiography in only seven cases. The response to surgery comprised significant overall improvement of global LV ejection fraction (LVEF) during rest and of all variables in stress testing. This LVEF recovery correlated significantly with that of peak ejections rate, a variable of myocardial contractility. Contrastingly, right ventricular ejection fraction (RVEF) at rest decreased slightly but significantly without correlation to preoperative RVEF or LVEF. In comparisons between patients with congestive heart failure or angina at rest as dominant symptom, the former group showed greater depression of preoperative watt and LVEF but better postoperative recovery of these variables, while right ventricular deterioration was significant only in the latter. Postoperative recovery was best in patients with poor preoperative LV function (LVEF ? 20%), even when surgery comprised only aneurysmectomy in isolated but ungraftable LAD disease (5 cases). The observed RV deterioration may be ‘nonspecific', but it must be kept in mind as a side effect of the operation, as it detracts unpredictably from postoperative ventricular recovery. Patients with well preserved preoperative LVEF, small LV aneurysm and marginal expected postaneurysmectomy changes according to LaPlace's law are probably at risk, and surgery should then instead be directed towards preserving the remaining viable myocardium by direct revascularization.     

Left ventricular diastolic function in patients on maintenance haemodialysis

SUMMARY: The aim of this study was to elucidate the differences in left ventricular (LV) diastolic function between patients on maintenance haemodialysis (HD) with LV hypertrophy (LVH) and those with LVH from other causes. Twenty HD patients (HD group), 11 patients with hypertensive heart disease (HHD group), 11 with hypertrophic cardiomyopathy (HCM group) and 11 age-matched healthy individuals (N group) were examined using echocardiography. Compared with the HCM group, the HD and HHD groups had smaller total LV wall thickness and left atrial dimension, a higher ratio of LV end-diastolic dimension to LV posterior wall thickness, a shorter isovolumic relaxation time and a higher ratio of peak flow velocity of early to late LV fillings (E/A). There was a correlation between LV mass index or E/A and systolic blood pressure. These results indicate that HD patients have an LV diastolic dysfunction similar to that observed in HHD patients but which is less severe than that found in HCM patients. It seems reasonable to control hypertension in HD patients in order to favourably influence LV diastolic function.     

Surgical treatment of cardiac fibroma in a child with left ventricular noncompaction

Surgical treatment of cardiac fibroma is rare in patients with left ventricular noncompaction (LVNC). Although several case reports regarding cardiac fibroma have been published, resection in a patient with LVNC has not been described. Here, we describe the surgical treatment of left ventricular fibroma in a child with LVNC. We resected a cardiac fibroma in a 10‐year‐old boy with LVNC to control ventricular arrhythmia. Partial resection with careful tumor dissection was performed to avoid endocardial damage and entering the ventricular cavity. The postoperative course was uneventful, and the patient remains asymptomatic without heart failure or arrhythmia. Surgical excision of cardiac fibroma can be performed safely with excellent results, even in a child with LVNC.     

Intra-Aortic Balloon Pumping: Theory and Practice Experience with 325 Patients

Intra-aortic balloon pumping to support the failing circulation is now an accepted therapeutic modality. The device is simple. Insertion can be accomplished rapidly and efficiently in emergency rooms, coronary care units, cardiac catheterization suites and operating rooms, preoperatively, intraoperatively and postoperatively. The hemodynamic effects are immediate and predictable, and the accruing clinical results show increasing survival and hospital discharge rates. In these institutions, mechanical support of the circulation by this and more advanced methods has been formalized within the responsibility of a Circulatory Support Service.
The purpose of this Report is to summarize some observations and analyses which have been made during care of 325 consecutive postcardiotomy and/or postinfarction cardiogenic shock patients. Historical, theoretical, basic, and applied aspects and current results are included. Foremost are the straightforward concepts of considering the heart as a pump, the failing heart as a failing pump and intra-aortic balloon pumping as a temporary intravascular, auxiliary pump, capable of stabilizing or reversing that failure if utilized early in its evolution.     

Arterial stiffness correlated with cardiac remodelling in patients with chronic kidney disease

BACKGROUND: It is well known that both pressure and volume overloads contribute to left ventricular hypertrophy (LVH) and left ventricular dilatation in patients with chronic kidney disease (CKD). Few studies have evaluated the association between increased pulse wave velocity (PWV) and LVH in CKD patients not yet receiving dialysis. The purpose of this study was to assess the relationship between arterial stiffness and cardiac remodelling in patients with CKD, and to determine the independent factors associated with increased left ventricular mass index (LVMI) and left ventricular volume index (LVVI). METHODS: This cross-sectional study included 96 patients with CKD. Echocardiography and measurement of arterial stiffness by PWV were performed. Clinical and echocardiographic parameters were compared and analysed. RESULTS: Associated with the increase of PWV, there were significant trends for progressive increase in LVMI, LVH, LVVI, left ventricular dilatation and left atrium in CKD patients. Multivariate regression analysis revealed that decreased PWV, in addition to increased haemoglobin and the use of beta-blocker, was an independent determinant associated with decrease in LVMI and LVVI. CONCLUSION: Our study demonstrated the progressive structural remodelling of left ventricle and left atrium in CKD patients associated with increased severity of arterial stiffness. PWV was an important determinant of LVMI and LVVI in CKD patients.     

Cardiac replacement therapies: outcomes and costs for heart transplantation versus circulatory assist

Objectives: Growing number of patients with terminal heart failure and a shortage of heart donors have increased use of short- and long-term mechanical circulatory support (MCS). Few studies have analyzed survival rates and healthcare costs for heart transplantation (HTx), with or without extracorporeal membrane oxygenation (ECMO) and left ventricular assist device (LVAD).

Design: In a retrospective, single-center study, data were analyzed from patients listed for HTx who died on the waiting list (DWL, n?=?12), underwent HTx (n?=?206), had ECMO as bridge to HTx (ECHTx, n?=?15), or received LVAD treatment, either isolated (LVAD, n?=?19) or bridging to HTx (LVADHTx, n?=?26) during 2005–2012. Survival and hospital costs were assessed.

Results: One- and five-year survival rates were 96% and 83% for the LVADHTx group, 92% and 81% for HTx, 70% and 70% for ECHTx, 48% and 36% for LVAD and 0% for the DWL group (overall survival, p?Conclusion: The LVADHTx and HTx groups showed excellent one- and five-year survival. The combined group of DWL and HTx patients had similar survival to the combined groups of MCS, but use of LVAD pre-transplant quadrupled the cost.     

The Relationship between Cardiac Troponins and Left Ventricular Mass Index in Patients with Chronic Renal Failure

The abstract of this study was accepted as an oral presentation in the 10^th Annual Meeting of the ESC Working Group on Echocardiography, December 6–9, 2006, Prague, Czech Republic     

Durable left ventricular assist device implantation in extremely obese heart failure patients

Left ventricular assist devices (LVADs) have improved clinical outcomes and quality of life for those with end‐stage heart failure. However, the costs and risks associated with these devices necessitate appropriate patient selection. LVAD candidates are becoming increasingly more obese and there are conflicting reports regarding obesity’s effect on outcomes. Hence, we sought to evaluate the impact of extreme obesity on clinical outcomes after LVAD placement. Consecutive LVAD implantation patients at our center from June 2008 to May 2016 were studied retrospectively. We compared patients with a body mass index (BMI) ≥40 kg/m² (extremely obese) to those with BMI < 40 kg/m² with respect to patient characteristics and surgical outcomes, including survival. 252 patients were included in this analysis, 30 (11.9%) of whom met the definition of extreme obesity. We found that patients with extreme obesity were significantly younger (47[33, 57] vs. 60[52, 67] years, P < 0.001) with fewer prior sternotomies (16.7% vs. 36.0%, P = 0.04). They had higher rates of pump thrombosis (30% vs. 9.0%, P = 0.003) and stage 2/3 acute kidney injury (46.7% vs. 27.0%, P = 0.003), but there were no differences in 30‐day or 1‐year survival, even after adjusting for age and clinical factors. Extreme obesity does not appear to place LVAD implantation patients at a higher risk for mortality compared to those who are not extremely obese; however, extreme obesity was associated with an increased risk of pump thrombosis, suggesting that these patients may require additional care to reduce the need for urgent device exchange.     

Assessed value of high-sensitivity cardiac troponin T for cardiovascular disease among CKD patients

Objective To analyze the relationship between serum high-sensitivity cardiac troponin T (hs-cTnT) and cardiovascular disease (CVD) among non-dialysis chronic kidney disease (CKD) patients, and to further explore its value of evaluating and predicting CVD in this population. Methods Five hundred and fifty-seven non-dialysis CKD patients were involved in this cross-sectional study. The relationship between serum hs-cTnT and CVD was analyzed using comparison between groups and regression analysis, and its value on assessing cardiac structure and function was evaluated by ROC curves. Results Median level of hs-cTnT was 13 (7–29) ng/L, with 1.7% undetectable, 46.4% greater than 99th percentile of the general population. Multivariate analysis suggested that compared with the lowest quartile of hs-cTnT, the highest quartile was approximately six times as likely to develop into LVH (OR, 6.515; 95% CI, 3.478–12.206, p?<?0.05) and 18 times as likely to progress to left ventricular diastolic dysfunction(OR, 18.741; 95% CI, 2.422–145.017, p?<?0.05). And Ln cTnT level had a more modest association with LVEF (OR, ?1.117; 95% CI, ?5.839 to ?0.594; p?<?0.05). When evaluated as a screening test, the area under the curve of ROC curves for hs-cTnT was 0.718, 0.788 and 0.736, respectively (p?<?0.05). With a specificity of 90% as a diagnostic criterion, the value of hs-cTnT to evaluate LVH, LVEF?Conclusions In CKD non-dialysis population, hs-cTnT and NT-proBNP were valuable for evaluating LVH, left ventricular systolic dysfunction and left ventricular diastolic dysfunction.     

Concomitant mitral valve repair and left ventricular reconstruction in a patient with chronic ischemic mitral regurgitation and inferior left ventricular aneurysm

The surgical approach to ischemic mitral regurgitation with concomitant inferior left ventricular aneurysm remains uncertain in terms of the indication for operation and the short-and long-term outcomes. We performed concomitant mitral valve repair, left ventricular reconstruction, and aortic valve replacement on a 71-year-old male with severe ischemic mitral regurgitation, inferior left ventricular aneurysm, and degenerative aortic regurgitation. Postoperative status was in New York Heart Association functional class I without mitral regurgitation 8 months after operation. We discuss, and review the procedures reported in the literature.