Atrial function in heart transplant recipients operated with the bicaval technique

Objectives: In heart transplantation (HTx) with the bicaval technique the whole right atrium (RA) is donor tissue while the left atrium (LA) consists of both donor and recipient tissue. The aims of the study were to describe atrial function in comparison with healthy controls and to identify determinants of dysfunction. Design: Forty-three patients and 30 controls were retrospectively included. Echocardiography was performed within 24 h of right heart catheterization (RHC) (HTx recipients). Results: The peak longitudinal atrial systolic strain (?) described the atrial reservoir function. The LA and RA reservoir function were reduced versus controls (LA-? 18?±?8 versus 44?±?10%; RA-? 22?±?10 versus 69?±?17%, p?<?0.001). There were moderate relationships between atrial-? and ventricular filling pressure (r?=??0.64 for LA-?; r?=??0.57 for RA-?). In a multiple regression analysis the LA-? was determined by pulmonary capillary wedge pressure (PCWP) and LA minimum volume index (r?=??0.71) while RA-? was dependent on the right ventricular ? (r?=??0.77). Conclusions: Atrial reservoir function is markedly reduced in HTx recipients related to elevated PCWP and LA-enlargement in the LA and in the RA impaired longitudinal right ventricular function.     

The long‐term influence of repetitive cellular cardiac rejections on left ventricular longitudinal myocardial deformation in heart transplant recipients

The aim of the study was to evaluate the long‐term influence of repeated acute cellular rejections on left ventricular longitudinal deformation in heart transplantation (HTX) patients. One hundred and seventy‐eight HTX patients were included in the study. Rejections were classified according to the International Society of Heart and Lung Transplantation (ISHLT) classification (0R–3R). Patients were divided into three groups according to rejection scores (RSs). Group 1: <50% of biopsies with 1R rejection and no ≥2R rejections; Group 2: ≥50% of biopsies with 1R rejection or one biopsy with ≥2R rejection; Group 3: ≥Two biopsies with ≥2R rejections. All patients had a comprehensive echocardiographic examination and coronary angiography. We found significantly decreasing global longitudinal strain (GLS) comparing to rejection groups (GLS group 1: ?16.8 ± 2.4 (%); GLS group 2: ?15.9 ± 3.3 (%); GLS group 3: ?14.5 ± 2.9 (%), P = 0.0003). After excluding patients with LVEF < 50% or vasculopathy, GLS was still significantly reduced according to RS groups (P = 0.0096). Total number of 1R and 2R rejections correlated significant to GLS in a linear regression model. In contrast, we found fractional shortening and LVEF to be unaffected by repeated rejections. In conclusion, repeated cardiac rejections lead to impaired graft function as detected by decreasing magnitude of GLS. In contrast, traditional systolic graft function surveillance by LVEF did not correlate to rejection burden.     

Impact of Residual Mitral Regurgitation on Right Ventricular Systolic Function After Left Ventricular Assist Device Implantation

Significant mitral regurgitation (MR) is thought to decrease after left ventricular assist device (LVAD) implantation, and therefore repair of mitral valve is not indicated in current practice. However, residual moderate and severe MR leads to pulmonary artery pressure increase, thereby resulting in right ventricular (RV) dysfunction during follow‐up. We examined the impact of residual MR on systolic function of the right ventricle by echocardiography after LVAD implantation. This study included 90 patients (mean age: 51.7 ± 10.9 years, 14.4% female) who underwent LVAD implantation (HeartMate II = 21, HeartWare = 69) in a single center between December 2010 and June 2014. Echocardiograms obtained at 3–6 months and over after implantation were analyzed retrospectively. RV systolic function was graded as normal, mild, moderate, and severely depressed. MR (≥moderate) was observed in 43 and 44% of patients at early and late period, respectively. Systolic function of the RV was severely depressed in 16 and 9% of all patients. Initial analysis (mean duration of support 174.3 ± 42.5 days) showed a statistically significant correlation between less MR and improved systolic function of RV (P = 0.01). Secondary echocardiographic analysis (following a mean duration of support of 435.1 ± 203 days) was also statistically significant for MR degree and RV systolic dysfunction (P = 0.008). Residual MR after LVAD implantation may cause deterioration of RV systolic function and cause right‐sided heart failure symptoms. Repair of severe MR, in selected patients such as those with severe pulmonary hypertension and depressed RV, may be considered to improve the patient's clinical course during pump support.     

Pattern of resolution of pulmonary hypertension,long‐term allograft right ventricular function,and exercise capacity in high‐risk heart transplant recipients listed under oral sildenafil

Unresponsive pulmonary hypertension (PH) implies poor posttransplant outcomes. Data on late adaptation of the right ventricle (RV) are still few. This study evaluated three‐yr RV function and remodeling, exercise capacity, and hemodynamic data in a selected group of patients initially disqualified because of PH. Between May 2005 and December 2009, 31 consecutive patients were qualified for oral sildenafil because of unresponsive PH at baseline right heart catheterization (RHC). After a 12‐wk trial, RHC disclosed PH reversibility (mean PVR: 5.41 ± 3 Wood units, mean TPG 14.5 ± 5.6 mmHg, and mean systolic PAP 68.9 ± 15.1 mmHg), allowing listing even though as high‐risk procedures. All patients underwent heart transplantation. RV failure developed in three patients (9.6%), and hospital mortality was 3.2%. Protocol RHC disclosed pulmonary hemodynamic profile normalization within the third postoperative month, allowing weaning from sildenafil in the 30 hospital survivors. One‐ and three‐yr RHCs confirmed stable PH reversal (n = 26, all three‐yr survivors). Parameters of late RV function and remodeling proved satisfactory. Parameters of functional capacity (Vo₂ peak 19.7 ± 3.6 mL/kg/min and slope VE/Vco₂ 34.8 ± 2.7) proved homogeneous to those measured in transplant recipients with normal preoperative pulmonary artery pressure. Oral sildenafil is effective in allowing candidacy, safe transplantation, and long‐term survival in PH recipients initially disqualified.     

Tricuspid Annular Plane Systolic Excursion (TAPSE) correlates with mean pulmonary artery pressure especially 10 years after pediatric heart transplantation

Tricuspid annular plane systolic excursion (TAPSE) is important in the noninvasive echocardiographic assessment of right heart function. This retrospective observational study shows correlations of TAPSE with invasive right heart catheterization parameters after pediatric heart transplantation (HTx). The study included patients after pediatric HTx with cardiac catheterizations in 2018/2019 and measurement of TAPSE (n = 52 patients with 57 examinations; 50.9% adults, 52.6% female, median age: 18.54 years). TAPSE was compared with normal values. Stepwise, linear and multiple regression were used to show influencing variables on TAPSE. Mean TAPSE z-score was −3.48 (SD: 2.25) and 68.4% of HTx-recipients showed abnormally reduced TAPSE (z-score ←2) compared to normal values. Multiple regression (p-value <0.001; corrected R² = 0.338) showed significant correlations of time since HTx (p-value <0.001) and mPAP (p-value: 0.008) with TAPSE z-scores. Divided into subgroups (time since HTx <10 and ≥10 years), TAPSE and mPAP correlated only ≥10 years after HTx (p-value = 0.002). This study provides data of TAPSE even ≥10 years after pediatric HTx. Most patients showed a decreased TAPSE early after HTx, which improved over time. TAPSE z-scores correlated significantly with time since HTx and mPAP, especially ≥10 years post-HTx. Therefore, TAPSE must be used carefully in the early follow-up.     

Ketamine reduce left ventricular systolic and diastolic function in patients with ischaemic heart disease

Objective: Ketamine may be followed by a general increase in haemodynamics and oxygen consumption, which may be of concern in patients with ischaemic heart disease. The purpose of this study was to evaluate the effect of ketamine on left ventricular (LV) systolic and diastolic function by different modalities of echocardiography and tissue Doppler imaging in patients with ischaemic heart disease. Methods and Results: Prospective observational study of 11 patients acting as own control based on echocardiographic imaging before and after bolus ketamine 0.5 mg/kg. Simpson's 2 D‐volumetric method was used to quantify left ventricular volume and ejection fraction. General global LV deformation was assessed by Speckle tracking ultrasound, systolic LV longitudinal displacement was assessed by Tissue Tracking score index and the diastolic function was evaluated from changes in early‐(E') and atrial (A') peak velocities during diastole. Average heart rate (34%) and blood pressure (35%) increased significantly after ketamine (P<0.0001). Mean tissue tracking score index decreased from 11.2±2.3 to 8.3±2.6 (P=0.005) and Global Speckle tracking 2D strain from 17.7±2.7 to 13.7±3.6 (P=0.0014) indicating a decrease in LV global systolic function. The E'/A' ratio decreased from 1.11±0.43 to 0.81±0.46 (P=0.044) indicating impaired relaxation. Conclusion: Different modalities of echocardiography in combination with tissue Doppler indicate both diminished systolic and diastolic function after ketamine administration in patients with ischaemic heart disease.     

Endocrine heart after lung transplantation: increased brain natriuretic peptide is related to right ventricular function

Brain natriuretic peptide (BNP) increases in proportion to the extent of right ventricular dysfunction in pulmonary hypertension and after heart transplantation. No data are available after lung transplantation. Clinical, biological, respiratory, echocardiographic characteristics and circulating BNP and its second messenger cyclic guanosine monophosphate (cGMP) were determined in thirty matched subjects (10 lung‐, 10 heart‐transplant recipients (Ltx, Htx) and 10 healthy controls). Eventual correlations between these parameters were investigated. Heart rate and pulmonary arterial blood pressure were slightly increased after transplantation. Creatinine clearance was decreased. Mean of forced expiratory volume in 1 s was 76.6 ± 5.3% and vital capacity was 85.3 ± 6.4% of the predicted values in Ltx. BNP was similarly increased in Ltx and Htx, as compared with control values (54.1 ± 14.2 and 45.6 ± 9.2 vs. 6.2 ± 1.8 pg/ml, respectively). Significant relationships were observed between plasma BNP and cGMP values (r = 0.62; P < 0.05 and r = 0.75; P < 0.01, in Ltx and Htx) and between BNP and right ventricular fractional shortening and tricuspid E/Ea ratio in Ltx (r = ?0.75 and r = 0.93; P < 0.01, respectively). BNP is increased after lung transplantation, like after heart transplantation. The relationships observed suggest that the cardiac hormone might counterbalance possible deleterious effects of lung‐transplantation on right functioning of patient’s heart.     

Dominance of free wall radial motion in global right ventricular function of heart transplant recipients

Assessment of right ventricular (RV) function using conventional echocardiography might be inadequate as the radial motion of the RV free wall is often neglected. Our aim was to quantify the longitudinal and the radial components of RV function using three‐dimensional (3D) echocardiography in heart transplant (HTX) recipients. Fifty‐one HTX patients in stable cardiovascular condition without history of relevant rejection episode or chronic allograft vasculopathy and 30 healthy volunteers were enrolled. RV end‐diastolic (EDV) volume and total ejection fraction (TEF) were measured by 3D echocardiography. Furthermore, we quantified longitudinal (LEF) and radial ejection fraction (REF) by decomposing the motion of the RV using the ReVISION method. RV EDV did not differ between groups (HTX vs control; 96 ± 27 vs 97 ± 2 mL). In HTX patients, TEF was lower, however, tricuspid annular plane systolic excursion (TAPSE) decreased to a greater extent (TEF: 47 ± 7 vs 54 ± 4% [?13%], TAPSE: 11 ± 5 vs 21 ± 4 mm [?48%], P < .0001). In HTX patients, REF/TEF ratio was significantly higher compared to LEF/TEF (REF/TEF vs LEF/TEF: 0.58 ± 0.10 vs 0.27 ± 0.08, P < .0001), while in controls the REF/TEF and LEF/TEF ratio was similar (0.45 ± 0.07 vs 0.47 ± 0.07). Current results confirm the superiority of radial motion in determining RV function in HTX patients. Parameters incorporating the radial motion are recommended to assess RV function in HTX recipients.     

Metabolic syndrome in heart transplantation: impact on survival and renal function

The aim of our study was to analyze the early presence of metabolic syndrome (MS) in heart transplant (HTx) patients, and to assess its long‐term impact on survival and renal function. From January 2000 to October 2011, 253 consecutive HTx patients who survived more than 90 days were included. MS was diagnosed if patients met revised NCEP‐ATP III criteria at HTx or within 3 months post‐HTx. The prevalence of MS was 41.9%. Patients with MS had greater overall mortality after a mean follow‐up of 1700 ± 979 days (log‐rank test, P = 0.020). In the multivariate analysis, and subject to a minimum survival of 90 days, the only independent predictor variables of long‐term mortality were the presence of MS (OR, odds ratio 2.087, P = 0.032), and rejection episodes (OR 1.833, P = 0.001). Patients with MS had worse renal function at baseline both in plasma creatinine (1.19 ± 0.44 vs. 1.03 ± 0.29 mg/dl, P = 0.002) and glomerular filtration rate estimated by modified diet in renal disease (73.60 ± 26.76 vs. 87.30 ± 43.55 ml/min/1.73m², P = 0.005), whereas progressive impairment of renal function was of equal magnitude in both groups. The presence of MS prior to transplant or its development within the first 3 months identified a subgroup at greater risk of mortality and long‐term renal dysfunction.     

Vitamin D deficiency, CD4+CD28null cells and accelerated atherosclerosis in chronic kidney disease

Aim: Cardiovascular disease (CVD) is the leading cause of death among chronic kidney disease (CKD) patients. The role of vitamin D remains controversial in this process. We evaluated the relationship between 25‐hydroxyvitamin D, abnormal T helper cells (CD4+CD28null cells), systemic inflammation and atherosclerosis in CKD patients. Methods: A total of 101 stage 4–5 non‐dialysis CKD patients and 40 healthy controls were studied. Common carotid artery intima media thickness (CCA‐IMT) was measured with an ultrasound system. 25(OH) vitamin D and highly sensitive C‐reactive protein (hsCRP) were measured in serum by enzyme linked immunosorbent assay. The frequency of circulating CD4+CD28null cells was evaluated by flowcytometry. Results: CKD subjects exhibited higher CCA‐IMT (0.71 ± 0.01 vs 0.56 ± 0.01 mm, P < 0.0001), hsCRP (90.7 ± 5.8 vs 50.1 ± 8.6 µg/mL, P < 0.0001), CD4+CD28null cell frequency (9.1 ± 0.9 vs 3.6 ± 0.5%, P < 0.0001) and lower 25(OH) vitamin D levels (17.9 ± 1.9 vs 26.9 ± 3.5 ng/mL, P < 0.0001). In CKD subjects, serum 25 (OH) vitamin D level showed a strong inverse correlation with CCA‐IMT (r = ?0.729, P < 0.0001) and correlated with CD4+CD28null cell frequency (r = ?0.249, P = 0.01) and hsCRP (r = ?0.2, P = 0.047). We also noted correlation of IMT with patient age (r = 0.291, P = 0.004) and CD4+CD28null cells (r = 0.34, P = 0.001). On multiple regression analysis, 25(OH) vitamin D level, diabetic status and CD4+CD28null cell frequency exhibited independent association with IMT in CKD subjects. Conclusions: Vitamin D deficiency, inflammatory activation and higher frequency of CD4+CD28null T lymphocyte population correlate with preclinical atherosclerotic changes in CKD population. These findings suggest possible linkage between vitamin D metabolism and T cell modulation – abnormalities that may contribute to development of atherosclerosis in CKD.     

Right Ventricle Dysfunction in Patients With Adult Cystic Fibrosis Enlisted for Lung Transplant

Knowledge of preoperative right heart function of adult patients with cystic fibrosis (CF) awaiting lung transplant (LUTX) is limited. The echocardiography of adult patients with CF enlisted for LUTX was retrospectively analyzed and compared with standards and invasive analyses (right heart catheterization, multigated radionuclide ventriculography). We included 49 patients (reported as mean ± standard deviation; 29 ± 9 years of age; forced expiratory volume in first second of expiration, 31% ± 11% predicted; lung allocation score, 36 ± 5; invasive mean pulmonary artery pressure, 17 ± 5 mm Hg; multigated radionuclide ventriculography right ventricle [RV] ejection fraction, 50% ± 9%). Patients had increased RV end-diastolic area, RV wall thickness, and increased pulmonary artery acceleration time with subnormal tricuspid annular plane systolic excursion, tissue Doppler positive peak systolic velocity, and fraction area change. Subnormal tricuspid annular plane systolic excursion (< 23 mm), tissue Doppler positive peak systolic velocity (< 14 cm/s), and fraction area change (< 49%) had high sensitivity and negative predictive value in predicting impaired RV.ejection fractionA good correlation between echocardiographic estimated and invasively measured systolic pulmonary artery pressure was observed (R² = 0.554, P < .001). Adults with CF awaiting LUTX have morphologic alterations of the right heart, with subclinical impairment of RV systolic function. Echocardiography may be used as a bedside, repeatable, and reliable noninvasive test to screen further deterioration in RV function while on the waiting list for LUTX. More prospective follow-up echocardiographic studies are necessary to confirm such a hypothesis.     

Comparison of Continuous‐Flow and Pulsatile‐Flow Blood Pumps on Reducing Pulmonary Artery Pressure in Patients With Fixed Pulmonary Hypertension

Pulmonary hypertension (PH) is considered as a risk factor for morbidity and mortality in patients undergoing heart transplantation. Recently, left ventricular assist device (LVAD) implantation has been increasingly used in reducing pulmonary artery pressure (PAP) in patients with PH unresponsive to medical therapy. Herein, we aimed to compare the efficacy of continuous‐flow and pulsatile‐flow blood pumps on the improvement of PH in mechanical circulatory support patients. Twenty‐seven patients with end‐stage heart failure who underwent LVAD implantation surgery were enrolled. Fifteen of them (55.6%) had continuous‐flow pump (HeartWare Ventricular Assist System, HeartWare, Inc., Miramar, FL, USA), and 12 of them (44.4%) had pulsatile pump (Berlin Heart EXCOR ventricular assist device, Berlin Heart AG, Berlin, Germany). The efficacy of LVADs on the improvement of PH was compared between continuous‐flow and pulsatile pumps by the evaluation of systolic PAP, tricuspid annular plane systolic excursion (TAPSE), right ventricular systolic motion (RVSM), right ventricular ejection fraction (RVEF), and grade of tricuspid insufficiency (TI) for each of the study participants. All of the 15 patients who underwent continuous‐flow blood pump implantation surgery (Group 1) were male with a mean age of 46.9 ± 11.7 years, and in pulsatile‐flow blood pump implanted participants (Group 2), the mean age was 40.6 ± 16.8 years, all of whom were also male (P = 0.259). Mean follow‐up was 313.7 ± 241.3 days in Group 1 and 448.7 ± 120.7 days in Group 2 (P = 0.139). In Group 1, mean preoperative and postoperative systolic PAP were measured as 51.7 ± 12.2 mm Hg and 22.2 ± 3.4 mm Hg, respectively, while those in Group 2 were 54.5 ± 7.5 mm Hg and 33.9 ± 6.4 mm Hg, respectively. A significantly greater decrease in systolic PAP was noticed in patients with continuous‐flow blood pumps (P = 0.023); however, no statistically significant difference was found when we considered the change in TAPSE between study groups (P = 0.112). A statistical significance in the alteration of RVEF, RVSM, and the grade of TI during study visits was not found between the study groups (P = 0.472, P = 0.887, and P = 0.237, respectively). Although the two studied types of LVADs were found to be effective in reducing PAP in heart transplantation candidates with PH, lesser postoperative systolic PAP values were achieved in patients who underwent continuous‐flow pump implantation surgery.     

Improvement of right ventricular function with transcatheter aortic valve implantation

Background and aim. It has been demonstrated that right ventricular systolic dysfunction develops soon after surgical aortic valve replacement (s-AVR). While the impact of s-AVR or TAVI on the function of the left ventricle has been studied with various imaging modalities, little is known about the impact on right ventricular function (RVF). In the current study, we evaluated the impact of TAVI on RVF using conventional echocardiography parameters. Methods and results. Echocardiography was performed prior to 24 h, 1 month and 6 months after TAVI. RVF was assessed using (1) tricuspid annular plane systolic excursion (TAPSE); (2) RV Tissue Doppler Imaging (S’); (3) right ventricular systolic pressure (RVSP); (4) Fractional area change (FAC); and (5) RV ejection fraction (RVEF). TAVI was performed through the subclavian artery in two patients and femoral artery in 48 patients with an Edwards Sapien XT valve. TAVI was performed on 50 patients between the dates of December 2012 and June 2013. After TAVI, a statistically significant improvement was observed for all parameters related to RVF (RVSP, RVEF, TAPSE, FAC, RVTDI S’). During the 1st and 6th months this statistically significant improvement continued in TAPSE and FAC, and there was no deterioration in RVSP, RVEF, and RVTDI S during the 1st month but a statistically significant improvement continued in the 6th month. Conclusion. RVF assessed by conventional echocardiography did not deteriorate after TAVI in early and midterm follow-up. Further, TAVI provides improvement of RVF and can safely and efficiently be performed in patients with impaired RVF.     

Brain natriuretic peptide and right heart dysfunction after heart transplantation

Heart transplantation (HT) should normalize cardiac endocrine function, but brain natriuretic peptide (BNP) levels remain elevated after HT, even in the absence of left ventricular hemodynamic disturbance or allograft rejection. Right ventricle (RV) abnormalities are common in HT recipients (HTx), as a result of engraftment process, tricuspid insufficiency, and/or repeated inflammation due to iterative endomyocardial biopsies. RV function follow‐up is vital for patient management as RV dysfunction is a recognized cause of in‐hospital death and is responsible for a worse prognosis. Interestingly, few and controversial data are available concerning the relationship between plasma BNP levels and RV functional impairment in HTx. This suggests that infra‐clinical modifications, such as subtle immune system disorders or hypoxic conditions, might influence BNP expression. Nevertheless, due to other altered circulating molecular forms of BNP, a lack of specificity of BNP assays is described in heart failure patients. This phenomenon could exist in HT population and could explain elevated BNP plasmatic levels despite a normal RV function. In clinical practice, intra‐individual change in BNP over time, rather than absolute BNP values, might be more helpful in detecting right cardiac dysfunction in HTx.     

High tacrolimus trough level variability is associated with rejections after heart transplant

Tacrolimus, the major immunosuppressant after heart transplant (HTx) therapy, is a narrow therapeutic index drug. Hence, achieving stable therapeutic steady state plasma concentrations is essential to ensure efficacy while avoiding toxicity. Whether high variability in steady state concentrations is associated with poor outcomes is unknown. We investigated the association between tacrolimus trough level variability during the first year post‐HTx and outcomes during and beyond the first postoperative year. Overall, 72 patients were analyzed for mortality, of whom 65 and 61 were available for rejection analysis during and beyond the first year post‐HTx, respectively. Patients were divided into high (median >28.8%) and low tacrolimus level variability (<28.8%) groups. Mean tacrolimus levels did not differ between the groups (12.7 ± 3.4 ng/mL vs 12.8 ± 2.4 ng/mL, P = .930). Patients in the high variability group exhibited higher long‐term rejection rate (median total rejection score: 0.33 vs 0, P = .04) with no difference in rejection scores within the first year post‐HTx. Multivariate analysis showed that high tacrolimus trough level variability was associated with >8‐fold increased risk for any rejection beyond the first year post‐HTx (P = .011). Mortality was associated only with cardiovascular complications (P = .018), with no effect of tacrolimus through level variability.     

Sufentanil preserves hemodynamics and left ventricular function in patients with ischemic heart disease

Objective: Sufentanil has been reported to provide stable hemodynamics similar to other opioids. However, it has not been reliably established whether this stability can be attributed only to Sufentanil and translates into fully preserved left ventricular (LV) function. The purpose of this study was to evaluate the effect of Sufentanil on hemodynamics and LV systolic and diastolic function using invasive monitoring and echocardiography in patients with ischemic heart disease. Methods: Prospective observational study of thirty patients acting as their own control undergoing echocardiographic imaging before and after bolus Sufentanil 1.5–2.0 μg/kg. Full invasive hemodynamic monitoring was established before Sufentanil administration. Global LV systolic function was evaluated with a global longitudinal peak systolic strain (GLPSS) by speckle tracking ultrasound; systolic displacement by tissue tracking (TT) and diastolic function was evaluated using Doppler tissue imaging and pulse wave Doppler. Results: Hemodynamic monitoring showed a minor decline in systolic blood pressure from 159 to 154 mmHg (P=0.046). No changes were observed in the cardiac index, stroke volume index and heart rate. An unchanged TT score index (9.9 vs. 10.2 mm, P=0.428) and GLPSS (14.3 vs. 14.5%, P=0.658) indicated preserved LV global systolic function and unchanged E'/A' (0.95 vs. 0.89, P=0.110) and E/E' ratio (15.4 vs. 14.9, P=0.612) indicated unchanged diastolic function. Conclusion: Sufentanil preserves hemodynamic parameters as well as echocardiographic indices of LV systolic and diastolic function in patients with ischemic heart disease (IHD).     

Effect of everolimus vs calcineurin inhibitors on quality of life in heart transplant recipients during a 3‐year follow‐up: Results of a randomized controlled trial (SCHEDULE)

The Sc andinavian he art transplant everolimus d e novo st u dy with ear l y calcineurin inhibitors avoidanc e (SCHEDULE) trial was a 12 month, randomized, open‐label, parallel‐group trial that compared everolimus (EVR; n=56) to conventional CsA (n=59) immunosuppression. Previously, we reported that EVR outperformed CsA in improving renal function and coronary artery vasculopathy, despite a higher rejection rate with EVR. This study aimed to compare the effects of these treatments on quality of life (QoL). Within five post‐operative days, patients (mean age 50±13 years, 27% women) were randomized to EVR or a standard CsA dosage (CsA group). This study assessed quality of life (QoL), based on the Short Form‐36, EuroQol‐5D, and Beck Depression Inventory (BDI). Assessments were performed pre‐HTx and 12 and 36 months post‐HTx. At 12 and 36 months, the groups showed similar improvements in Short Form‐36 measures (at pre‐HTx, 12 and 36 months the values were as follows: Physical component summary: EVR: 31.5±110.9, 49.1±9.7, and 47.9±10.6; P<.01; CsA: 32.5±8.2, 48.4±8.5, and 46.5±11.5; P<.01; mental component summary: EVR: 46.0±12.0, 51.7±11.9, and 52.1±13.0; P<.01; CsA: 38.2±12.5, 53.4±7.1, and 54.3±13.0; P<.01); similar decrease in mean BDI (EVR: 10.9±10.2, 5.4±4.7, and 8.1±9.0; P<.01; CsA: 11.8±7.1, 6.3±5.4, and 6.2±6.5; P<.01); and similar Euro Qol‐improvements. Thus, in this small‐sized study, EVR‐based and conventional CsA immunosuppressive strategies produced similar QoL improvements.     

The effects of bilateral lung transplantation on ventilatory efficiency,oxygen uptake and the right heart: a two‐yr follow‐up

Habedank D, Ewert R, Hummel M, Dandel M, Habedank F, Knosalla C, Lehmkuhl HB, Anker SD, Hetzer R. The effects of bilateral lung transplantation on ventilatory efficiency, oxygen uptake and the right heart: a two‐yr follow‐up.
Clin Transplant 2011: 25: E38–E45. © 2010 John Wiley & Sons A/S. Abstract: Background: This study was to examine the course of ventilation/perfusion mismatch (VE/VCO₂‐slope) before and during two‐yr follow‐up after bilateral lung transplantation (BLTx) and to relate exercise parameters with the reverse right ventricular remodeling. Methods: We prospectively examined 20 patients (nine women; age 46.0 ± 13.0 yr) by cardiopulmonary exercise testing (before and at 3, 6, 12, and 24 months after BLTx), and by echocardiography and blood gas analysis. Etiology of pulmonary failure was chronic obstructive pulmonary disease as well (n = 8), pulmonary hypertension (n = 7), idiopathic fibrosis (n = 3), others (n = 2). Results: The VE/VCO₂‐slope before BLTx was 47.5 (interquartile range 24.5) and declined at 3 months ?25.9%, 6 months ?30.9%, 12 months ?33.9%, and 24 months ?35.1% (all p ≤ 0.003) and was then not different from normal. The right ventricular end diastolic diameter RVEDd narrowed from 35.0 (22.5) before to 31.0 (9.0) mm at 3 months after LTx. Similarly, right ventricular systolic pressure (RV_sys) decreased from 53.6 ± 28.3 to 26.2 ± 5.2 mmHg (all p < 0.01). RVEDd correlated with VE/VCO₂‐slope before (p < 0.0001) but not after BLTx. PeakVO₂ increased from 10.0 ± 2.3 mL/min per kg before BLTx by 86.5% at 24 months (p < 0.01). Conclusions: The functional status (VE/VCO₂‐slope, peakVO₂) improves quickly after lung transplantation and is accompanied by reverse remodeling of the right heart. A correlation between exercise parameters and right heart function was found before BLTx only.     

The immediate hemodynamic effects of enhanced external counterpulsation on the left ventricular function

Abstract

Objectives. Enhanced external counterpulsation (EECP) is a non-invasive therapy with long-term anti-anginal effects offered to patients with refractory angina pectoris. The purpose of the present study was to investigate the effect of EECP on myocardial contractility measured as global longitudinal strain (GLS) during EECP treatment. Design. Patients with known refractory angina were enrolled by invitation and underwent 1 h of EECP treatment. Two-dimensional echocardiography and Doppler echocardiography were performed before and during EECP treatment with 15-minute intervals. The peak diastolic/systolic blood pressure ratio (D/S ratio) was monitored with finger pletysmography. GLS was assessed offline with speckle-tracking software (EchoPAC GE Healthcare USA). Results. Twenty patients were included (mean age 65.0 ± 8.2; 85% males). During EECP treatment, the systolic function of the left ventricle (LV) expressed in terms of an increasing GLS (? 17.9 vs. ? 16.2% p < 0.05) and a rising cardiac output (5.5 vs. 4.6 l/min p < 0.05) were improved. D/S ratio during the EECP procedure was inversely correlated to LV filling pressure (E/Em ratio r = ? 0.5 p = 0.035). Conclusions. In conclusion, we demonstrated that EECP improved left ventricular GLS and systolic function in an acute setting. Future studies must explore whether these immediate hemodynamic changes are associated to the clinical effect of EECP treatment.