How to demonstrate the reversibility of end-organ function before implantation of left ventricular assist device in INTERMACS profile 2 patients?

Increased serum Wisteria floribunda agglutinin positive Mac-2 binding protein (Mac-2 binding protein glycosylation isomer) in chronic heart failure: a pilot study

BACKGROUND

Serum Wisteria floribunda agglutinin positive Mac-2 binding protein (WFA⁺-M2BP) or Mac-2 Binding Protein Glycosylation Isomer (M2BPGi) is a novel biomarker currently applied for evaluating hepatic fibrosis. The aim of this study was to evaluate the utility of serum WFA⁺-M2BP level as a biomarker in chronic heart failure (HF) patients with abnormal liver function.

METHODS AND RESULTS

Fifty chronic HF patients who underwent measurement of serum WFA⁺-M2BP were evaluated. The median value of serum WFA⁺-M2BP was 0.88 (interquartile range 0.48-1.29) cut-off index, and positive WFA⁺-M2BP (≥ 1.00 cut-off index) was observed in 22 (44%). Elevated WFA + -M2BP was associated with longer HF history, older age, female sex, valvular heart disease, decreased estimated glomerular filtration rate (eGFR), albumin, and cholinesterase. Stepwise multiple regression analysis showed that HF history, eGFR, and albumin were independent determinants of serum WFA⁺-M2BP values. Repeated measurements of serum WFA⁺-M2BP suggested association between the decrease of WFA⁺-M2BP and improvement of New York Heart Association (NYHA) functional class.

CONCLUSIONS

Elevation of serum WFA⁺-M2BP showed a high prevalence in chronic HF patients with abnormal liver function with relation to HF history, decreased hepatic protein synthesis, and renal dysfunction. Our results suggest that serum WFA⁺-M2BP may be a novel biomarker of chronic HF.

Reversible Motor Paralysis and Early Cardiac Rehabilitation in Patients With Advanced Heart Failure Receiving Left Ventricular Assist Device Therapy

Advanced heart failure (HF) is sometimes complicated with brain impairment because of a microthrombosis caused by decreased left ventricular contraction or reduced brain circulation. Some patients may recover after left ventricular assist device (LVAD) implantation. However, little is known about the perioperative therapeutic strategy in patients suffering from such complications, particularly from a cardiac rehabilitation viewpoint. We report on a 58-year-old male patient with a previous history of poliomyelitis and a light paralysis in the left upper extremity, who suffered left hemiplegia with no evidence of stroke after hemodynamic deterioration. The combination therapy of perioperative cardiac rehabilitation and LVAD therapy improved his left hemiplegia as well as activities of daily living, and the patient was discharged on foot on postoperative day 72 after briefing the family on LVAD home management. Early initiation of cardiac rehabilitation before LVAD implantation may be a key for the smooth discharge and resocialization of patients suffering from brain impairment complicated with advanced HF.

Model for end-stage liver disease excluding international normalized ratio (MELD-XI) score predicts heart transplant outcomes: Evidence from the registry of the United Network for Organ Sharing

BACKGROUND

Hepato-renal function is a valuable predictor of success after left ventricular assist device therapy and heart transplantation. Hence, we analyzed the importance of the Model for End-stage Liver Disease excluding international normalized ratio (MELD-XI) score to outcomes after heart transplant.

METHODS

Adults undergoing heart transplant from the United Network for Organ Sharing (UNOS) database were identified (1994 to 2014). Individual MELD-XI scores were calculated; patients were stratified by MELD-XI quartiles (Q1 to Q4). Multivariate logistic regression and the Cox proportional hazard model were implemented to determine any association between MELD-XI scores, survival and other outcomes.

RESULTS

From 39,711 patients undergoing OHT during the study period, MELD-XI score [median 10.7 (interquartile range 7.0 to 14.4)] was calculated for 36,005 patients (76% male and 75% white, 34% Status 1A). Higher MELD-XI scores had higher rates of pre-transplant extracorporeal membrane oxygenation, intra-aortic balloon pump, inotrope use and mechanical ventilation (p < 0.001 for all). Adjusted long-term mortality (median follow-up 8.1 years) was associated with MELD-XI score (hazard ratio [HR] 1.021 [1.016 to 1.026], p < 0.001). The highest MELD-XI quartile was associated with an HR 1.364 [1.255 to 1.482] risk of mortality compared with Q1. MELD-XI score was also associated with increased post-transplant infections (adjusted HR Q4 vs Q1: 1.364 [1.153 to 1.614], p < 0.001), stroke (adjusted HR Q4 vs Q1: 1.410 [1.074 to 1.852], p = 0.013), dialysis (adjusted HR Q4 vs Q1: 3.982 [3.386 to 4.683], p < 0.001), rejection (adjusted HR Q4 vs Q1: 1.519 [1.286 to 1.795], p = 0.003) and prolonged hospitalization (adjusted HR Q4 vs Q1: 1.635 [1.429 to 1.871], p < 0.001).

CONCLUSION

Hepato-renal dysfunction, measured with MELD-XI score, predicts morbidity and mortality in patients undergoing orthotopic heart transplantation. Etiology of hepato-renal dysfunction should be sought and treated before heart transplantation.

Current status of extracorporeal ventricular assist devices in Japan

Extracorporeal VADs are less expensive, their prices reimbursable by the health insurance being about one-sixth of those of implantable VADs in Japan. However, a disadvantage is that, in Japan, their use is restricted to hospitals, necessitating prolonged hospitalization, reducing the patients' quality of life. According to the Japanese registry for Mechanically Assisted Circulatory Support, the survival rate does not differ significantly between patients with extracorporeal and implantable VADs. As in Europe and North America, extracorporeal VADs in Japan are commonly used as Bridge to Decision or Bridge to Recovery. Extracorporeal VADs are switched to implantable VADs as a Bridge-to-Bridge strategy after stabilization or when cardiac function recovery fails. They are also used as right ventricular assist devices (RVADs) in patients with right heart failure. A special characteristic of extracorporeal VADs in Japan is their frequent use as a Bridge to Candidacy. In Japan, indications for implantable VADs are restricted to patients registered for heart transplantation. Therefore, in patients who cannot be registered for transplantation because of transient renal dysfunction, etc., due to heart failure, extracorporeal VADs are used first, and then replaced by implantable VADs after transplant registry is done. Here, we describe the current status of extracorporeal VADs in Japan, focusing on the environmental backgrounds, along with a review of the relevant literature.