The incidence, risk factors, and outcomes associated with late right-sided heart failure in patients supported with an axial-flow left ventricular assist device

BACKGROUND

Early right-sided heart failure (RHF) after left ventricular assist device (LVAD) implantation is associated with increased mortality, but little is known about patients who develop late RHF (LRHF). We evaluated the incidence, risk factors, and clinical impact of LRHF in patients supported by axial-flow LVADs.

METHODS

Data were analyzed from 537 patients enrolled in the HeartMate II (HM II; Thoratec/St. Jude) destination therapy clinical trial. LRHF was defined as the development of clinical RHF accompanied by the need for inotropic support occurring more than 30 days after discharge from the index LVAD implant hospitalization. Clinical variables, quality of life, rehospitalizations, and survival were compared between patients with and without LRHF.

RESULTS

LRHF developed in 41 patients (8%), with a median time to LRHF of 480 days. A higher preoperative blood urea nitrogen and increased central venous pressure-to-pulmonary capillary wedge pressure ratio were independent predictors of LRHF. The Michigan and HMII RHF risk scores were both associated with an increased likelihood of LRHF (p < 0.05). Patients with LRHF had worse quality of life according to the Kansas City Cardiomyopathy Questionnaire (61 ± 26 vs 70 ± 21; p < 0.05), poorer functional capacity by 6-minute walk distance (275 ± 189 m vs 312 ± 216 m; p < 0.05), and more rehospitalizations (6 vs 3; p < 0.001). LRHF was associated with decreased survival (p < 0.001).

CONCLUSIONS

LRHF is an important complication in patients with LVADs and is associated with worse quality of life, reduced functional capacity, more frequent hospitalizations, and worse survival compared with those without LRHF.

Hierarchical structures of cactus spines that aid in the directional movement of dew droplets

Three species of cactus whose spines act as dew harvesters were chosen for this study: Copiapoa cinerea var. haseltoniana, Mammillaria columbiana subsp. yucatanensis and Parodia mammulosa and compared with Ferocactus wislizenii whose spines do not perform as dew harvesters. Time-lapse snapshots of C. cinerea showed movement of dew droplets from spine tips to their base, even against gravity. Spines emanating from one of the areoles of C. cinerea were submerged in water laced with fluorescent nanoparticles and this particular areole with its spines and a small area of stem was removed and imaged. These images clearly showed that fluorescent water had moved into the stem of the plant. Lines of vascular bundles radiating inwards from the surface areoles (from where the spines emanate) to the core of the stem were detected using magnetic resonance imaging, with the exception of F. wislizenii that does not harvest dew on its spines. Spine microstructures were examined using SEM images and surface roughness measurements (Ra and Rz) taken of the spines of C. cinerea It was found that a roughness gradient created by tapered microgrooves existed that could potentially direct surface water from a spine tip to its base.This article is part of the themed issue 'Bioinspired hierarchically structured surfaces for green science'.

Effectiveness of a care bundle to reduce surgical site infections in patients having open colorectal surgery

Introduction In 2010 a care bundle was introduced by the Department of Health (DH) to reduce surgical site infections (SSIs) in England. To date, use of the care bundle has not been evaluated despite incorporating interventions with resource implications. The aim of this study was to evaluate the DH SSI care bundle in open colorectal surgery. Methods A prospective cohort design was used at two teaching hospitals in England. The baseline group consisted of 127 consecutive patients having colorectal surgery during a 6-month period while the intervention group comprised 166 patients in the subsequent 6 months. SSI and care bundle compliance data were collected using dedicated surveillance staff. Results Just under a quarter (24%) of the patients in the baseline group developed a SSI compared with just over a quarter (28%) in the care bundle group (p>0.05). However, compliance rates with individual interventions, both before and after the implementation of the bundle, were similar. Interestingly, in only 19% of cases was there compliance with the total care bundle. The single intervention that showed an associated reduction in SSI was preoperative warming (p=0.032). Conclusions The DH care bundle did not reduce SSIs after open colorectal surgery. Despite this, it is not possible to state that the bundle is ineffective as compliance rates before and after bundle implementation were similar. All studies evaluating the effectiveness of care bundles must include data for compliance with interventions both before and after implementation of the care bundle; poor compliance may be one of the reasons for the lower than expected reduction of SSIs.

Intensification of Medication Therapy for Cardiorenal Syndrome in Acute Decompensated Heart Failure

BACKGROUND

Worsening renal function in heart failure may be related to increased venous congestion, decreased cardiac output, or both. Diuretics are universally used in acute decompensated heart failure, but they may be ineffective and may lead to azotemia. We aimed to compare the decongestive properties of a urine output-guided diuretic adjustment and standard therapy for the management of cardiorenal syndrome in acute decompensated heart failure.

METHODS AND RESULTS

Data were pooled from subjects randomized to the stepwise pharmacologic care algorithm (SPCA) in the CARRESS-HF trial and those who developed cardiorenal syndrome (rise in creatinine >0.3 mg/dL) in the DOSE-AHF and ROSE-AHF trials. Patients treated with SPCA (n = 94) were compared with patients treated with standard decongestive therapy (SDT) that included intravenous loop diuretic use (DOSE-AHF and ROSE-AHF; n = 107) at the time of cardiorenal syndrome and followed for net fluid balance, weight loss, and changing renal function. The SPCA group had higher degrees of jugular venous pressure (P < .0001) at the time of cardiorenal syndrome. The group that received SPCA had more weight change (-3.4 ± 5.2 lb) and more net fluid loss (1.705 ± 1.417 L) after 24 hours than the SDT group (-0.8 ± 3.4 lb and 0.892 ± 1.395 L, respectively; P < .001 for both) with a slight improvement in renal function (creatinine change -0.1 ± 0.3 vs 0.0 ± 0.3 mg/dL, respectively; P = .03).

CONCLUSIONS

Compared with SDT, patients who received an intensification of medication therapy for treating persisting congestion had greater net fluid and weight loss without being associated with renal compromise.

Clinical epidemiology of heart failure with preserved ejection fraction (HFpEF) in comparatively young hospitalized patients

BACKGROUND

While heart failure with preserved ejection fraction (HFpEF) is primarily a disease of old age, risk factors that contribute to HFpEF are not limited to older patients. The objectives of this population-based observational study were to describe the clinical epidemiology of HFpEF in younger (<65 years) as compared with older (≥65 years) patients hospitalized with acute decompensated heart failure.

METHODS AND RESULTS

We reviewed the medical records of residents of central Massachusetts hospitalized with HFpEF at all 11 greater Worcester (MA) medical centers during the 5 study years of 1995, 2000, 2002, 2004, and 2006. Among the 2398 patients hospitalized with confirmed HFpEF, 357 (14.9%) were <65 years old. Younger patients were more likely to be male, non-Caucasian, obese, and to have a history of diabetes and chronic kidney disease than older patients with HFpEF. Younger patients hospitalized with HFpEF were less likely to have received commonly prescribed cardiac medications, had a longer hospital stay, and experienced significantly lower post-discharge death rates than older hospitalized patients.

CONCLUSION

While HFpEF is predominantly a disease of old age, data from longitudinal studies remain needed to identify risk factors in younger individuals that may predispose them to the development of HFpEF.

Hemodynamic effects of standard versus larger-capacity intraaortic balloon counterpulsation pumps

OBJECTIVE

Several recent trials have examined the clinical utility of intraaortic balloon counterpulsation pumps (IABPs) in cardiogenic shock and acute coronary syndromes. More recently, a larger-capacity 50 cc IABP was introduced into practice. No data comparing the hemodynamic effects of the 40 cc vs 50 cc IABP exist. Our aim was to explore the hemodynamic effects of the 50 cc IABP in real-world clinical practice.

METHODS

Demographic, hemodynamic, and laboratory data were retrospectively examined in 26 consecutive subjects treated with a 50 cc IABP and compared with 26 patients receiving a 40 cc IABP between 2012 and 2013. IABP tracings were analyzed within 24 hours of implantation in all patients. Pulmonary artery catheter data were available before and after IABP implantation in 20 subjects.

RESULTS

Baseline demographics, including body surface area, were similar between groups. Compared with the 40 cc IABP group, 50 cc IABP recipients showed higher augmented diastolic blood pressure, greater systolic unloading, and a larger reduction in pulmonary capillary occlusion pressure (PCOP). Percent diastolic augmentation was higher among 50 cc IABP recipients. Only 58% of subjects achieved <10 mm Hg of systolic unloading in the 40 cc group compared with 27% in the 50 cc group. For both the 40 cc and 50 cc IABPs, the magnitude of systolic unloading correlated inversely with PCOP and directly with the magnitude of diastolic augmentation.

CONCLUSION

In real-world practice, greater systolic unloading and diastolic augmentation were observed among 50 cc vs 40 cc IABP recipients. Future trials evaluating the clinical utility of the 50 cc IABP are required.

BK Virus Nephropathy in Heart Transplant Recipients

Polyomavirus-associated nephropathy (PVAN) has become an important cause of kidney failure in kidney transplant recipients. PVAN is reported to affect 1% to 7% of kidney transplant recipients, leading to premature transplant loss in approximately 30% to 50% of diagnosed cases. PVAN occurring in the native kidneys of solid-organ transplant recipients other than kidney only recently has been noted. We report 2 cases of PVAN in heart transplant recipients, which brings the total of reported cases to 7. We briefly review the literature on the hypothesized causes of PVAN in kidney transplant recipients and comment on whether these same mechanisms also may cause PVAN in other solid-organ transplant recipients. PVAN should be considered in the differential diagnosis when evaluating worsening kidney function. BK viremia surveillance studies of nonkidney solid-organ recipients should be conducted to provide data to assist the transplantation community in deciding whether regular monitoring of nonkidney transplant recipients for BK viremia is indicated.

Hitting the mark: blood pressure targets and agents in those with prevalent cardiovascular disease and heart failure

Blood pressure (BP) is one of the key modifiable risk factors for cardiovascular disease (CVD) both in primary and secondary prevention of disease. In this review, we discuss BP treatment in prevalent CVD and heart failure. Evidence for specific agents based on their neurohormonal effects and evidence for target values for systolic or diastolic BP are covered. The potential adverse effects of overtreatment of BP are also discussed. BP targets for those with CVD should generally be less than 140/90 mm Hg but require individualization of therapy for any further reduction based on the clinical setting.

The effect of the in vitro supplementation of exogenous long-chain fatty acids on bovine sperm cell function

This study aimed to investigate the effects of long-chain fatty acids (α-linolenic acid (ALA), docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA), linoleic acid (LA), oleic acid (OA) and palmitic acid (PA)) at concentrations of 10-100 µM, on extended bull spermatozoa stored in vitro for up to 7 days. Progressive linear motion (PLM), viability (Experiments 1-3), ability to penetrate artificial mucus (Experiment 1), reactive oxygen species (ROS; Experiment 2) and superoxide production (Experiment 3) were assessed. Spermatozoa maintained the ability to penetrate artificial mucus up to Day 4, irrespective of treatment. In Experiments 2 and 3, DHA and EPA had detrimental effects on PLM and viability. PA preserved PLM and viability at levels greater than the control (P<0.05), whilst keeping ROS levels to a minimum, particularly on Days 1 and 3 (P<0.01) when ROS generation peaked in other treatments. In contrast, superoxide production peaked on Day 0 (Experiment 3) and declined thereafter with no significant effect of fatty acid. This study supports the notion that superoxide dominates on Day 0, whereas its breakdown products, hydrogen peroxide and the hydroxyl radical as assessed by CM-H2DCFDA, contribute to ROS generation on subsequent days.