Treatment options in end-stage heart failure: where to go from here? Neth Heart J. 2012;20:167-175. [PMID: 22083426 PMCID: PMC3303031 DOI: 10.1007/s12471-011-0211-4]

Backwash Maneuver for HeartMate3 Inflow Thrombosis: Experience From Two Cases

The ingested pump inflow thrombus, although rare, is a potentially life-threatening complication of left ventricular assist devices. During the last years, the backwash maneuver is considered an alternative method to pump replacement for the treatment of inflow thrombosis, showing high success rate in selected patients with HeartWare HVAD devices. However, that was not the case in our present report, in which we detail the application of this method in two HeartMate3 patients with ingested pump inflow thrombus. Washing out the thrombus was not feasible in either case, possibly due to mechanical aspects of the inflow part of the HeartMate3 pump. As a result, we remain skeptical regarding the use of the method in HeartMate3 patients with inflow thrombosis.

Phytochemistry of Genus Buxus and Pharmacology of Cyclovirobuxine D

BACKGROUND

Genus Buxus plants, commonly known as "boxwood", are widely distributed in China. The stems, branches, and leaves of the plant are traditionally used for rheumatism, toothache, chest pain, abdominal gas, and other diseases. However, an overview of the genus Buxus remains to be provided.

PURPOSE

To provide a scientific basis for the appropriate use and further research the recent advancements in the traditional usage, phytochemistry, and, pharmacology of Buxus.

STUDY DESIGN

Chemical composition and pharmacological correlation studies through a literature review.

METHODS

Between 1970 and 2023, the available data concerning Buxus was compiled from online scientific sources, such as Sci-Finder, PubMed, CNKI, Google Scholar, and the Chinese Pharmacopoeia. Plant names were verified from "The Plant List" (http://www.theplantlist.org/).

RESULTS

To date, 266 structurally diverse chemicals have been extracted and identified from the genus Buxus. Alkaloids constitute one of its primary bioactive phytochemicals. A summary of the channels of action of Cyclovirobuxine D on the cytotoxicity of a variety of cancers has been provided.

CONCLUSION

Numerous findings from contemporary phytochemical and pharmacological studies support the traditional use, facilitating its application. Further research is necessary to address various shortcomings, including the identification of the active ingredients and quality control of the genus Buxus.

Chronic care for heart failure patients: Who to refer back to the general practitioner?-Experiences of the Dutch integrated heart failure care model

OBJECTIVE

The number of patients with heart failure (HF) and corresponding burden of the healthcare system will increase significantly. The Dutch integrated model, 'Transmural care of HF Patients' was based on the European Society of Cardiology (ESC) guidelines and initiated to manage the increasing prevalence of HF patients in primary and secondary care and stimulate integrated care. It is unknown how many HF patients are eligible for back-referral to general practitioners (GPs), which is important information for the management of chronic HF care. This study aims to evaluate clinical practice of patients for whom chronic HF care can be referred from the cardiologist to the GP based on the aforementioned chronic HF care model.

DESIGN AND METHODS

A retrospective case record-based study was conducted, which included all chronic HF patients registered in the cardiology information systems of two different hospitals. Subsequently, 200 patients were randomly selected for evaluation. The following patients were considered eligible for referral to the GP: 1/Stable HF patients with reduced left ventricular ejection fraction (LVEF), 2/Stable HF patients with a recovered LVEF and 3/Stable HF patients with a preserved LVEF, 4/HF, palliative setting.

RESULTS

Of the 200 patients, 17% was considered eligible for referral to the GP. This group consisted of 5% patients with a reduced LVEF, 10.5% patients with recovered LVEF and 1.5% patients with a preserved LVEF. Main indicators for HF care by cardiologists were active cardiac disease other than HF (39.5%), recent admission for HF (29.5%) or a recent adjustment in HF medication (7.5%).

CONCLUSION

Applying the chronic HF care model of the 'Transmural care of HF patients' and the ESC-guidelines, results in an important opportunity to further optimise HF integrated care and to deal with the increasing number of HF patients referred to the hospital.

Effects of the atrium on intraventricular flow patterns during mechanical circulatory support

Simulations of the ventricular flow patterns during left ventricular assist device (LVAD) support are mainly performed with idealized cylindrical inflow, neglecting the influence of the atrial vortex. In this study, the influence of the left atrium (LA) on the intra-ventricular flow was investigated via Computational Fluid Dynamics (CFD) simulations. Ventricular flow was simulated by a combined Eulerian (carrier flow)/Lagrangian (particles) approach taking into account either the LA or a cylindrical inflow section to mimic a fully support condition. The flow deviation at the mitral valve, the blood low-velocity volume as well as the residence time and shear stress history of the particles were calculated. Inclusion of the LA deflects the flow at the mitral valve by 25°, resulting in an asymmetric flow jet entering the left ventricle. This reduced the ventricular low-velocity volume by 40% (from 6.4 to 3.9 cm³), increased (40%) the shear stress experienced by particles and correspondingly increased (27%) their residence time. Under the studied conditions, the atrial geometry plays a major role in the development of intraventricular flow patterns. A reliable prediction of blood flow dynamics and consequently thrombosis risk analysis within the ventricle requires the consideration of the LA in computational simulations.

A Novel Hybrid Membrane VAD as First Step Toward Hemocompatible Blood Propulsion

Heart failure is a raising cause of mortality. Heart transplantation and ventricular assist device (VAD) support represent the only available lifelines for end stage disease. In the context of donor organ shortage, the future role of VAD as destination therapy is emerging. Yet, major drawbacks are connected to the long-term implantation of current devices. Poor VAD hemocompatibility exposes the patient to life-threatening events, including haemorrhagic syndromes and thrombosis. Here, we introduce a new concept of artificial support, the Hybrid Membrane VAD, as a first-of-its-kind pump prototype enabling physiological blood propulsion through the cyclic actuation of a hyperelastic membrane, enabling the protection from the thrombogenic interaction between blood and the implant materials. The centre of the luminal membrane surface displays a rationally-developed surface topography interfering with flow to support a living endothelium. The precast cell layer survives to a range of dynamically changing pump actuating conditions i.e., actuation frequency from 1 to 4 Hz, stroke volume from 12 to 30 mL, and support duration up to 313 min, which are tested both in vitro and in vivo, ensuring the full retention of tissue integrity and connectivity under challenging conditions. In summary, the presented results constitute a proof of principle for the Hybrid Membrane VAD concept and represent the basis for its future development towards clinical validation.

Fabrication and Characterization of Drug-Loaded Conductive Poly(glycerol sebacate)/Nanoparticle-Based Composite Patch for Myocardial Infarction Applications

Heart tissue engineering is critical in the treatment of myocardial infarction, which may benefit from drug-releasing smart materials. In this study, we load a small molecule (3i-1000) in new biodegradable and conductive patches for application in infarcted myocardium. The composite patches consist of a biocompatible elastomer, poly(glycerol sebacate) (PGS), coupled with collagen type I, used to promote cell attachment. In addition, polypyrrole is incorporated because of its electrical conductivity and to induce cell signaling. Results from the in vitro experiments indicate a high density of cardiac myoblast cells attached on the patches, which stay viable for at least 1 month. The degradation of the patches does not show any cytotoxic effect, while 3i-1000 delivery induces cell proliferation. Conductive patches show high blood wettability and drug release, correlating with the rate of degradation of the PGS matrix. Together with the electrical conductivity and elongation characteristics, the developed biomaterial fits the mechanical, conductive, and biological demands required for cardiac treatment.

Vasoresponsiveness in patients with heart failure (VASOR): protocol for a prospective observational study

BACKGROUND

Vasoplegia is a severe complication which may occur after cardiac surgery, particularly in patients with heart failure. It is a result of activation of vasodilator pathways, inactivation of vasoconstrictor pathways and the resistance to vasopressors. However, the precise etiology remains unclear. The aim of the Vasoresponsiveness in patients with heart failure (VASOR) study is to objectify and characterize the altered vasoresponsiveness in patients with heart failure, before, during and after heart failure surgery and to identify the etiological factors involved.

METHODS

This is a prospective, observational study conducted at Leiden University Medical Center. Patients with and patients without heart failure undergoing cardiac surgery on cardiopulmonary bypass are enrolled. The study is divided in two inclusion phases. During phase 1, 18 patients with and 18 patients without heart failure are enrolled. The vascular reactivity in response to a vasoconstrictor (phenylephrine) and a vasodilator (nitroglycerin) is assessed in vivo on different timepoints. The response to phenylephrine is assessed on t1 (before induction), t2 (before induction, after start of cardiotropic drugs and/or vasopressors), t3 (after induction), t4 (15 min after cessation of cardiopulmonary bypass) and t5 (1 day post-operatively). The response to nitroglycerin is assessed on t1 and t5. Furthermore, a sample of pre-pericardial fat tissue, containing resistance arteries, is collected intraoperatively. The ex vivo vascular reactivity is assessed by constructing concentrations response curves to various vasoactive substances using isolated resistance arteries. Next, expression of signaling proteins and receptors is assessed using immunohistochemistry and mRNA analysis. Furthermore, the groups are compared with respect to levels of organic compounds that can influence the cardiovascular system (e.g. copeptin, (nor)epinephrine, ANP, BNP, NTproBNP, angiotensin II, cortisol, aldosterone, renin and VMA levels). During inclusion phase 2, only the ex vivo vascular reactivity test is performed in patients with (N = 12) and without heart failure (N = 12).

DISCUSSION

Understanding the difference in vascular responsiveness between patients with and without heart failure in detail, might yield therapeutic options or development of preventive strategies for vasoplegia, leading to safer surgical interventions and improvement in outcome.

TRIAL REGISTRATION

The Netherlands Trial Register (NTR), NTR5647. Registered 26 January 2016.

Management and outcomes of left ventricular assist device-associated endocarditis: a systematic review

Background

Left ventricular assist device (LVAD)-associated endocarditis remains poorly studied, especially in newer continuous-flow LVADs (CF-LVADs). The aim of this review was to assess outcomes of patients with LVAD-associated endocarditis, as stratified by CF-LVAD and pulsatile LVAD (P-LVAD) use as well as by different interventions and pathogen types.

Methods

An electronic search was performed to identify studies in the English literature on LVAD-associated endocarditis.

Results

Overall, 16 articles with 26 patients were included; seven had CF-LVADs and 19 had P-LVADs; time to development of endocarditis was 91 days (152 vs. 65 days, respectively, P=0.05). Eleven of 25 patients were treated with antibiotics only. Remaining 14 patients received antibiotics, however, they also underwent additional surgical intervention. One patient was treated with embolization alone for mycotic aneurysm and was therefore excluded. At a median follow-up time of 344 days post implant, there was no difference in overall mortality between CF-LVAD and P-LVAD-associated endocarditis patients (57.9% vs. 42.9%, P=0.81). Patients who underwent additional surgical intervention had higher overall survival compared to those treated with antibiotics alone (71.4% vs. 27.3%, P=0.07); with no difference in outcomes amongst those who underwent surgical device exchange as compared to heart transplantation (80.0% vs. 66.7%; P=0.23).

Conclusions

Compared to patients with P-LVADs, CF-LVAD patients appeared to be resistant to early development of LVAD-associated endocarditis. There was a trend towards high survival observed amongst patients who underwent additional surgical intervention as compared to those treated with antibiotics alone, with no difference amongst surgical device exchange as compared to heart transplantation. Advantages of additional surgical intervention vs. medical therapy alone deserves further exploration to determine its applicability in CF-LVADs.

Influence of turbulent shear stresses on the numerical blood damage prediction in a ventricular assist device

The blood damage prediction in rotary blood pumps is an important procedure to evaluate the hemocompatibility of such systems. Blood damage is caused by shear stresses to the blood cells and their exposure times. The total impact of an equivalent shear stress can only be taken into account when turbulent stresses are included in the blood damage prediction. The aim of this article was to analyze the influence of the turbulent stresses on the damage prediction in a rotary blood pump's flow. Therefore, the flow in a research blood pump was computed using large eddy simulations. A highly turbulence-resolving setup was used in order to directly resolve most of the computed stresses. The simulations were performed at the design point and an operation point with lower flow rate. Blood damage was predicted using three damage models (volumetric analysis of exceeded stress thresholds, hemolysis transport equation, and hemolysis approximation via volume integral) and two shear stress definitions (with and without turbulent stresses). For both simulations, turbulent stresses are the dominant stresses away from the walls. Here, they act in a range between 9 and 50 Pa. Nonetheless, the mean stresses in the proximity of the walls reach levels, which are one order of magnitude higher. Due to this, the turbulent stresses have a small impact on the results of the hemolysis prediction. Yet, turbulent stresses should be included in the damage prediction, since they belong to the total equivalent stress definition and could impact the damage on proteins or platelets.

Grid-Induced Numerical Errors for Shear Stresses and Essential Flow Variables in a Ventricular Assist Device: Crucial for Blood Damage Prediction?

Adverse events due to flow-induced blood damage remain a serious problem for blood pumps as cardiac support systems. The numerical prediction of blood damage via computational fluid dynamics (CFD) is a helpful tool for the design and optimization of reliable pumps. Blood damage prediction models primarily are based on the acting shear stresses, which are calculated by solving the Navier–Stokes equations on computational grids. The purpose of this paper is to analyze the influence of the spatial discretization and the associated discretization error on the shear stress calculation in a blood pump in comparison to other important flow quantities like the pressure head of the pump. Therefore, CFD analysis using seven unsteady Reynolds-averaged Navier–Stokes (URANS) simulations was performed. Two simple stress calculation indicators were applied to estimate the influence of the discretization on the results using an approach to calculate numerical uncertainties, which indicates discretization errors. For the finest grid with 19 × 106 elements, numerical uncertainties up to 20% for shear stresses were determined, while the pressure heads show smaller uncertainties with a maximum of 4.8%. No grid-independent solution for velocity gradient-dependent variables could be obtained on a grid size that is comparable to mesh sizes in state-of-the-art blood pump studies. It can be concluded that the grid size has a major influence on the shear stress calculation, and therefore, the potential blood damage prediction, and that the quantification of this error should always be taken into account.

Psychometric Validation of the Korean Version of the 9-Item European Heart Failure Self-Care Behaviour Scale

Heart failure (HF) is the most common cause of frequent hospitalizations and high mortality. Active engagement in self-care behaviors is an essential component of HF disease management. Although the 9-item European Heart Failure Self-care Behaviour Scale (EHFScBS-9) as a commonly used instrument has been validated in different languages, there is no validated tool for addressing self-care behaviors related to HF in Korea. This study aimed to validate the Korean version of the EHFScBS-9. A cross-sectional study was adopted. The EHFSeBS-9 was translated and back-translated into Korean. A convenience sample of 270 patients from an outpatient clinic participated. Reliability was assessed via an internal consistency analysis. Construct validity was tested with exploratory factor and confirmatory factor analysis. Criterion validity was assessed by measuring participants’ health literacy and general health status. Internal consistency was supported based on a Cronbach’s α of .84. We identified three well-fitting factors (consulting behaviors, fluid restriction, and adherence behaviors), which explained 71.85% of the variance in self-care. More self-care behaviors were associated with adequate health literacy and good general health status. The Korean version of the EHFSeBS-9 showed sufficient internal consistency and acceptable validity to support its usage among Korean HF patients.

Large eddy simulation in a rotary blood pump: Viscous shear stress computation and comparison with unsteady Reynolds-averaged Navier-Stokes simulation

PURPOSE:

Numerical flow analysis (computational fluid dynamics) in combination with the prediction of blood damage is an important procedure to investigate the hemocompatibility of a blood pump, since blood trauma due to shear stresses remains a problem in these devices. Today, the numerical damage prediction is conducted using unsteady Reynolds-averaged Navier-Stokes simulations. Investigations with large eddy simulations are rarely being performed for blood pumps. Hence, the aim of the study is to examine the viscous shear stresses of a large eddy simulation in a blood pump and compare the results with an unsteady Reynolds-averaged Navier-Stokes simulation.

METHODS:

The simulations were carried out at two operation points of a blood pump. The flow was simulated on a 100M element mesh for the large eddy simulation and a 20M element mesh for the unsteady Reynolds-averaged Navier-Stokes simulation. As a first step, the large eddy simulation was verified by analyzing internal dissipative losses within the pump. Then, the pump characteristics and mean and turbulent viscous shear stresses were compared between the two simulation methods.

RESULTS:

The verification showed that the large eddy simulation is able to reproduce the significant portion of dissipative losses, which is a global indication that the equivalent viscous shear stresses are adequately resolved. The comparison with the unsteady Reynolds-averaged Navier-Stokes simulation revealed that the hydraulic parameters were in agreement, but differences for the shear stresses were found.

CONCLUSION:

The results show the potential of the large eddy simulation as a high-quality comparative case to check the suitability of a chosen Reynolds-averaged Navier-Stokes setup and turbulence model. Furthermore, the results lead to suggest that large eddy simulations are superior to unsteady Reynolds-averaged Navier-Stokes simulations when instantaneous stresses are applied for the blood damage prediction.

Anticoagulation Control in Patients With Ventricular Assist Devices

Anticoagulation control has been associated with risk of thromboembolism and hemorrhage. Herein, we explore the relationship between anticoagulation control achieved in left ventricular assist device (LVAD) patients and evaluate the association with risk of thromboembolism and hemorrhage. Patients (19 years old or older) with a continuous flow LVAD placed from 2006 to 2012. Percent time spent in target range (PTTR) for international normalized ratio (INR) was estimated with target range of 2.0-3.0. Proportion of time spent in target range was categorized into PTTR > 60%, PTTR ≥ 50 < 60%, and PTTR < 50%. The relationship between PTTR and thromboembolism and hemorrhage was assessed. One hundred fifteen participants contributed 624.5 months of follow-up time. Only 20% of patients achieved anticoagulation control (PTTR > 60% for INR range of 2-3). After adjusting for chronic kidney disease, history of diabetes, history of atrial fibrillation, and age at implant, compared with patients with PTTR < 50%, the relative risk of thromboembolism in patients with PTTR ≥ 60% (hazard ratio [HR]: 0.37; 95% confidence interval [CI]: 0.14-0.96; p = 0.042) was significantly lower, but not for patients with a PTTR of ≥ 50 < 60% (HR: 0.21; 95% CI: 0.02-1.82; p = 0.16). The relative risk for hemorrhage was also significantly lower among patients with a PTTR ≥ 60% (HR: 0.45; 95% CI: 0.21-0.98; p = 0.045), but not among those with PTTR of ≥ 50 < 60% (HR: 0.47; 95% CI: 0.14-1.56; p = 0.22). This current study demonstrates that LVAD patients remain in the INR target range an average of 42.9% of the time. To our knowledge, this is the first report with regard to anticoagulation control as assessed by PTTR and its association with thromboembolism, hemorrhage, or death among patients with ventricular assist devices (VADs).

Incidence and predictors of vasoplegia after heart failure surgery

Objectives

Vasoplegia has been described as a complication after cardiac surgery, particularly in patients with a poor left ventricular ejection fraction. The aim of this study was to assess the incidence, survival and predictors of vasoplegia in patients undergoing heart failure surgery and to propose a risk model.

Methods

A retrospective study including heart failure patients who underwent surgical left ventricular restoration, CorCap implantation or left ventricular assist device implantation between 2006 and 2015. Patients were classified by the presence or absence of vasoplegia.

Results

Two hundred and twenty-five patients were included. The incidence of vasoplegia was 29%. The 90-day survival rate in vasoplegic patients was lower compared with non-vasoplegic patients (71% vs 91%, P  <   0.001). After adjusting for age, sex and surgical procedure, anaemia (OR 2.195; 95% CI 1.146, 4.204; P  =   0.018) and a higher thyroxine level (OR 1.140; 95% CI 1.033, 1.259; P  =   0.009) increased the risk of vasoplegia; a higher creatinine clearance (OR 0.980; 95% CI 0.965, 0.994; P  =   0.006) and beta-blocker use (OR 0.257; 95% CI 0.112, 0.589; P  =   0.001) decreased the risk. The risk model consisted of the same variables and could adequately identify patients at risk for vasoplegia.

Conclusions

Vasoplegia after heart failure surgery is common and results in a lower survival rate. Anaemia and a higher thyroxine level are associated with an increased risk on vasoplegia. In contrast, a higher creatinine clearance and beta-blocker use decrease the risk on vasoplegia. These factors are used in the risk model that may guide treatment strategy.

Comparison of quality of life between patients on the waiting list and heart transplant recipients

Objectives

To compare the quality of life (QOL) between wait-listed patients and heart transplant recipients.

Methods

Cross-sectional study of 56 adult patients at two institutions in Southern Brazil, 9(16%) wait-listed patients and 47(84%) transplant recipients. Data were collected from August to December 2012. QOL was assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), with scores ranging from zero to 100.

Results

There was statistically significant difference between the two groups in the overall QOL score (p=0.010) and in four dimensions. The mean rank was 16.9 in wait-listed patients and 30.7 in transplant recipients. Wait-listed patients presented the lowest for general health (9.1) and the highest scores for role-emotional (24.8). Transplant recipients obtained the highest scores for general health (32.2) and the lowest scores for bodily pain (29.1).

Conclusions

Undergoing a transplant has a positive impact on the QOL of recipients compared to that of patients awaiting transplantation.

Can the outcomes of mesenchymal stem cell-based therapy for myocardial infarction be improved? Providing weapons and armour to cells

Use of mesenchymal stem cell (MSC) transplantation after myocardial infarction (MI) has been found to have infarct-limiting effects in numerous experimental and clinical studies. However, recent meta-analyses of randomized clinical trials on MSC-based MI therapy have highlighted the need for improving its efficacy. There are two principal approaches for increasing therapeutic effect of MSCs: (i) preventing massive MSC death in ischaemic tissue and (ii) increasing production of cardioreparative growth factors and cytokines with transplanted MSCs. In this review, we aim to integrate our current understanding of genetic approaches that are used for modification of MSCs to enable their improved survival, engraftment, integration, proliferation and differentiation in the ischaemic heart. Genetic modification of MSCs resulting in increased secretion of paracrine factors has also been discussed. In addition, data on MSC preconditioning with physical, chemical and pharmacological factors prior to transplantation are summarized. MSC seeding on three-dimensional polymeric scaffolds facilitates formation of both intercellular connections and contacts between cells and the extracellular matrix, thereby enhancing cell viability and function. Use of genetic and non-genetic approaches to modify MSC function holds great promise for regenerative therapy of myocardial ischaemic injury.

Haemolysis as a first sign of thromboembolic event and acute pump thrombosis in patients with the continuous-flow left ventricular assist device HeartMate II

Background

Despite advances in pump technology, thromboembolic events/acute pump thrombosis remain potentially life-threatening complications in patients with continuous-flow left ventricular assist devices (CF-LVAD). We sought to determine early signs of thromboembolic event/pump thrombosis in patients with CF-LVAD, which could lead to earlier intervention.

Methods

We analysed all HeartMate II recipients (n = 40) in our centre between December 2006 and July 2013. Thromboembolic event/pump thrombosis was defined as a transient ischaemic attack (TIA), ischaemic cerebrovascular accident (CVA), or pump thrombosis.

Results

During median LVAD support of 336 days [IQR: 182–808], 8 (20 %) patients developed a thromboembolic event/pump thrombosis (six TIA/CVA, two pump thromboses). At the time of the thromboembolic event/pump thrombosis, significantly higher pump power was seen compared with the no-thrombosis group (8.2 ± 3.0 vs. 6.4 ± 1.4 W, p = 0.02), as well as a trend towards a lower pulse index (4.1 ± 1.5 vs. 5.0 ± 1.0, p = 0.05) and a trend towards higher pump flow (5.7 ± 1.0 vs. 4.9 ± 1.9 L m, p = 0.06).

The thrombosis group had a more than fourfold higher lactate dehydrogenase (LDH) median 1548 [IQR: 754–2379] vs. 363 [IQR: 325–443] U/L, p = 0.0001). Bacterial (n = 4) or viral (n = 1) infection was present in 5 out of 8 patients. LDH > 735 U/L predicted thromboembolic events/pump thrombosis with a positive predictive value of 88 %.

Conclusions

In patients with a CF-LVAD (HeartMate II), thromboembolic events and/or pump thrombosis are associated with symptoms and signs of acute haemolysis as manifested by a high LDH, elevated pump power and decreased pulse index, especially in the context of an infection.

Stem cells: An eventual treatment option for heart diseases

Stem cells are of global excitement for various diseases including heart diseases. It is worth to understand the mechanism or role of stem cells in the treatment of heart failure. Bone marrow derived stem cells are commonly practiced with an aim to improve the function of the heart. The majority of studies have been conducted with acute myocardial infarction and a few has been investigated with the use of stem cells for treating chronic or dilated cardiomyopathy. Heterogeneity in the treated group using stem cells has greatly emerged. Ever increasing demand for any alternative made is of at most priority for cardiomyopathy. Stem cells are of top priority with the current impact that has generated among physicians. However, meticulous selection of proper source is required since redundancy is clearly evident with the present survey. This review focuses on the methods adopted using stem cells for heart diseases and outcomes that are generated so far with an idea to determine the best therapeutic possibility in order to fulfill the present demand.

The diagnosis of left ventricular assist device thrombosis

The clinical course of a patient with a left ventricular assist device is described. A total of 6 weeks after device insertion, the lactate dehydrogenase (LDH) level increased to 2801 U/l despite adding low-molecular-weight heparin to acenocoumarol and aspirin. Pump thrombosis was suspected but unconfirmed by computed tomography. Increased pump power requirement did not occur. Instituting unfractionated heparin caused a drop in the LDH level. After discontinuing heparin, the LDH levels rose to 5529 U/l whereupon pump replacement was performed. LDH levels, combined with clinical deterioration and right heart catheterisation, led to the diagnosis of pump thrombosis.

Left ventricular assist device for end-stage heart failure: results of the first LVAD destination program in the Netherlands

Purpose

Mechanical circulatory support with a continuous-flow left ventricular assist device (LVAD) may be a valuable treatment in end-stage heart failure patients for an extended period of time. The purpose of this study was to evaluate the safety and efficacy of implantation of a continuous-flow LVAD in end-stage heart failure patients within the first destination program in the Netherlands.

Methods

A third-generation LVAD was implanted in 16 heart failure patients (age 61 ± 8; 81 % male; left ventricular ejection fraction 20 ± 6 %) as destination therapy. All patients were ineligible for heart transplant. At baseline, 3 and 6 months, New York Heart Association (NYHA) functional class, quality-of-life and exercise capacity were assessed. Clinical adverse events were registered.

Results

Survival at 30 days and 6 months was 88 and 75 %, respectively. In the postoperative phase, 6 (38 %) patients required continuous veno-venous haemofiltration for renal failure and 2 (13 %) patients required extracorporeal membrane oxygenation because of severe right ventricular failure. During follow-up, NYHA functional class and quality-of-life improved from 3.7 ± 0.1 to 2.3 ± 0.1 and 57 ± 5 to 23 ± 3 at 6 months (P < 0.001), respectively. The 6 min walking distance improved from 168 ± 42 m to 291 ± 29 m at 6 months (P = 0.001).

Conclusion

Continuous-flow LVAD therapy is a promising treatment for patients with end-stage heart failure ineligible for heart transplant.

Short-term effect of granulocyte colony-stimulating factor in dogs with severe myxomatous mitral valve disease

BACKGROUND

Use of granulocyte colony-stimulating factor (G-CSF) to treat damaged myocardium is a relatively new concept. Clinical beneficial and safety outcomes are still controversial.

OBJECTIVE

The aim of this study was to evaluate recruitment of hematopoietic stem cells and therapeutic efficacy of G-CSF in the treatment of myxomatous mitral valve disease (MMVD) of dogs.

ANIMALS AND METHODS

Thirty client-owned MMVD dogs with clinical signs of heart failure were enrolled in a prospective double-blind, randomized, placebo-controlled study to compare the short-term effect of G-CSF (n = 17) with control group (n = 13) for identical periods. Clinical, hematological, and cardiovascular assessments were performed on days 0, 1, 3, and 7. Follow-up examination was conducted four weeks after the study.

RESULTS

Dogs treated with G-CSF had a significantly elevated white blood cell (WBC) (×10(3)/μL) count at day 3 compared with baseline (from 10.23 ± 4.42 to 42.84 ± 11.84; P = .000). The WBC population was also changed (elevated neutrophils and decreased lymphocytes) and the numbers of CD34+ cells in the peripheral blood were also increased at day 3. However, the results of clinical, laboratory, and echocardiographic assessments did not differ significantly between the G-CSF treatment and control groups after four weeks.

CONCLUSIONS

G-CSF administration elevated the peripheral WBC count, especially neutrophils, and recruited hematopoietic stem cells. However, positive effects of G-CSF on cardiac function were not detected during short-term monitoring.

Treatment with atorvastatin is associated with a better prognosis in chronic heart failure with systolic dysfunction: results from The Daunia Heart Failure Registry

BACKGROUND

Few works have evaluated the effect of statins on left ventricular dysfunction in patients with chronic heart failure (CHF), by using tissue Doppler imaging (TDI). We therefore aimed to investigate whether atorvastatin treatment may influence prognosis and myocardial performance evaluated by TDI in subjects with CHF.

METHODS

Five hundred thirty-two consecutive CHF outpatients enrolled in a local registry, the Daunia Heart Failure Registry, were prospectively analysed. 195 patients with CHF and left ventricular ejection fraction (LVEF) ≤40 %, either in treatment with atorvastatin (N: 114) or without statins (N: 81), underwent TDI examination. Adverse events were evaluated during follow-up.

RESULTS

The atorvastatin group showed a lower incidence of adverse events (cardiac death: 0 % vs 7 %, p < 0.01), and better TDI performance (E/E' 15 ± 5.7 vs 18 ± 8.3, p < 001) than controls. Ischaemic CHF patients in treatment with atorvastatin also showed a lower incidence of adverse events (death: 10 % vs 26 %, p < 0.05; sustained ventricular arrhythmias: 5 % vs 19 %, p < 0.05, cardiac death: 0 vs 8 %, p < 0.05) and better TDI performance (E/E' ratio: 15.00 ± 5.68 vs 19.72 ± 9.14, p < 0.01; St: 353.70 ± 48.96 vs 303.33 ± 68.52 msec, p < 0.01) than controls. The association between atorvastatin and lower rates of cardiac death remained statistically significant even after correction in a multivariable analysis (RR 0.83, 95 % CI 0.71-0.96, p < 0.05 in CHF with LVEF ≤40 %; RR 0.77, 95 % CI 0.62-0.95, p < 0.05 in ischaemic CHF with LVEF ≤40 %).

CONCLUSIONS

Treatment with atorvastatin in outpatients with systolic CHF is associated with fewer cardiac deaths, and a better left ventricular performance, as assessed by TDI.

Liposomes as drug deposits in multilayered polymer films

The ex vivo growth of implantable hepatic or cardiac tissue remains a challenge and novel approaches are highly sought after. We report an approach to use liposomes embedded within multilayered films as drug deposits to deliver active cargo to adherent cells. We verify and characterize the assembly of poly(l-lysine) (PLL)/alginate, PLL/poly(l-glutamic acid), PLL/poly(methacrylic acid) (PMA), and PLL/cholesterol-modified PMA (PMAc) films, and assess the myoblast and hepatocyte adhesion to these coatings using different numbers of polyelectrolyte layers. The assembly of liposome-containing multilayered coatings is monitored by QCM-D, and the films are visualized using microscopy. The myoblast and hepatocyte adhesion to these films using PLL/PMAc or poly(styrenesulfonate) (PSS)/poly(allyl amine hydrochloride) (PAH) as capping layers is evaluated. Finally, the uptake of fluorescent lipids from the surface by these cells is demonstrated and compared. The activity of this liposome-containing coating is confirmed for both cell lines by trapping the small cytotoxic compound thiocoraline within the liposomes. It is shown that the biological response depends on the number of capping layers, and is different for the two cell lines when the compound is delivered from the surface, while it is similar when administered from solution. Taken together, we demonstrate the potential of liposomes as drug deposits in multilayered films for surface-mediated drug delivery.

Beta-blocker therapy in unstable severe heart failure, evidence or experience?

Currently, no evidence exists on the effects of beta-receptor blocker (BRB) treatment in patients with unstable severe heart failure. When confronted with this specific patient category, clinical experience in our centre has consistently guided us to lower the dose or stop BRB therapy. To share this experience, we present three clinical case scenarios and discuss background literature motivating our approach in these patients.

Influence of cyclovirobuxine D on intracellular [Ca(2+)] regulation and the expression of the calcium cycling proteins in rat myocytes

Our previous studies have shown that cyclovirobuxine D (CVB-D) ameliorated the cardiac function in heart failure rats. Considering the relationship between cardiac function and [Ca(2+)]i, and the role of calcium cycling on regulating [Ca(2+)]i, the present study was designed to evaluate the influence of CVB-D on the calcium transient of myocytes from neonatal rats and adult heart failure (HF) rats. The expression of calcium cycling proteins, including L-type calcium channel (LTCC), ryanodine receptor 2 (RYR2), sarcoplasmic reticulum calcium ATPase 2a (SERCA2a) and sodium-calcium exchanger (NCX), were investigated to explore the underlying mechanism. CVB-D increased the intensity of calcium transient, accelerated the process of calcium transient and attenuation in the neonatal and adult myocytes. Furthermore, CVB-D shortened T(peak) and T(attenuation) in the adult myocytes and slowed down the heart rate of neonatal myocytes. Besides, CVB-D increased the expression of RYR2 and SERCA2a, decreased the expression of NCX, but showed no significant effect on LTCC. Thus, it was concluded that CVB-D increased the release and uptake of Ca(2+) in systolic and diastolic period, respectively. CVB-D might not only facilitate the utilization of intracellular Ca(2+), but also prevent the loss of Ca(2+).