Congestive Heart Failure

Causes and treatment strategies of unilateral leaflet escape of bileaflet mechanical prosthetic heart valves after surgery: a case series

BACKGROUND

During the eleven years from 2010 to 2021, preliminary statistics have shown that Fuwai Hospital completed 23,571 mechanical valve replacements for various types of valves, and 1139 mechanical valve replacements were performed in Guangyuan First People's Hospital. Only two patients developed valve leaflet escape, so valve leaflet escape is a rare postoperative complication.

CASE PRESENTATION

In 2010 and 2021, two patients were selected after they had unilateral leaflet escape after having mechanical valve replacements in Fuwai Hospital of Chinese Academy of Medical Sciences and Guangyuan First People's Hospital. Both patients underwent reoperations with the classic operation and the new bileaflet mechanical prosthetic heart valve was sutured. The treatment of detached single lobe and distal vessel was comprehensively determined, and the condition was treated according to the patient's symptoms, CT results, ultrasound results and other test results, as well as whether this detached lobe caused any abnormal hemodynamics of the distal vessel. The patient with mechanical aortic valve escape completed the 10-year follow-up, and patient with mechanical mitral valve escape completed the 3-month follow-up. there was no thrombosis or hematoma at the embolic site; the patient had no lower limb symptoms.

CONCLUSIONS

The reason for the leaflet escape may be related to the valve design and the leaflet material. If the detached leaflets are damaged and if the distal blood vessels are affected, simultaneous surgical treatment is required. Those patients whose vessels were not damaged by the valve lobe should be carefully monitored.

Right heart failure: A narrative review for emergency clinicians

INTRODUCTION

Right heart failure (RHF) is a clinical syndrome with impaired right ventricular cardiac output due to a variety of etiologies including ischemia, elevated pulmonary arterial pressure, or volume overload. Emergency department (ED) patients with an acute RHF exacerbation can be diagnostically and therapeutically challenging to manage.

OBJECTIVE

This narrative review describes the pathophysiology of right ventricular dysfunction and pulmonary hypertension, the methods to diagnose RHF in the ED, and management strategies.

DISCUSSION

Right ventricular contraction normally occurs against a low pressure, highly compliant pulmonary vascular system. This physiology makes the right ventricle susceptible to acute changes in afterload, which can lead to RHF. Patients with acute RHF may present with an acute illness and have underlying chronic pulmonary hypertension due to left ventricular failure, pulmonary arterial hypertension, chronic lung conditions, thromboemboli, or idiopathic conditions. Patients can present with a variety of symptoms resulting from systemic edema and hemodynamic compromise. Evaluation with electrocardiogram, laboratory analysis, and imaging is necessary to evaluate cardiac function and end organ injury. Management focuses on treating the underlying condition, optimizing oxygenation and ventilation, treating arrhythmias, and understanding the patient's hemodynamics with bedside ultrasound. As RHF patients are preload dependent they may require fluid resuscitation or diuresis. Hypotension should be rapidly addressed with vasopressors. Cardiac contractility can be augmented with inotropes. Efforts should be made to support oxygenation while trying to avoid intubation if possible.

CONCLUSIONS

Emergency clinician understanding of this condition is important to diagnose and treat this life-threatening cardiopulmonary disorder.

[Hypertonic saline solution and high dose of diuretic, ¿what do we know and how can we use them in persistent congestion?]

The presence of decompensated heart failure continues to be a condition with high rates of hospitalization, impact on the health system, and quality of life for those who suffer it. The mainstay of treatment in these cases are diuretics. However, the resistance to this pharmacological group may occasionally occur, generating an inadequate negative fluid balance and persistence of congestion with negative clinical outcomes. Hypertonic saline solution with high doses of diuretic emerges as a therapeutic option for this group of patients with probable physiological, and clinical benefits on hospitalization and re-admission rates due to heart failure decompensation. A review of the most relevant aspects and benefits of this combination is discussed in this article.

Predisposing Factors for Severe Complications after Cataract Surgery: A Nationwide Population-Based Study

We conducted a retrospective group study to evaluate the potential systemic risk factors for major postoperative complications of cataract surgery. Individuals diagnosed with (n = 2046) and without (n = 8184) serious complications after cataract surgery were matched 1:4 for age, sex, and index date obtained using Taiwan’s National Health Insurance Research Database. The outcome was defined as at least one new inpatient or outpatient diagnosis of systemic disease one year before the index date. The effect of demographic data on postoperative complications was also analyzed in the multivariable model. Data were analyzed using univariate and multivariate conditional logistic regression models to calculate odds ratios (ORs) and 95% confidence intervals of the risk of developing serious complications. After the entire study interval, the major postoperative complications of cataract surgery were associated with the following systemic diseases: hypertension (adjusted OR (aOR) = 2.329, p < 0.001), diabetes mellitus (aOR = 2.818, p < 0.001), hyperlipidemia (aOR = 1.702, p < 0.001), congestive heart failure (aOR = 2.891, p < 0.001), rheumatic disease (aOR = 1.965, p < 0.001), and kidney disease needing hemodialysis (aOR = 2.942, p < 0.001). Additionally, demographic data including old age, higher urbanization level, higher level of care, and more frequent inpatient department visits were associated with a higher rate of postoperative complications. In conclusion, metabolic syndrome, chronic heart failure, end-stage renal disease, rheumatic disease, older age, and frequent inpatient department visits are correlated with the development of severe postoperative complications of cataract surgery. Therefore, cataract surgery patients should be informed about a higher possibility of postoperative complications.

Comparison between thulium laser vapoenucleation and plasmakinetic resection of the prostate in men aged 75 years and older in a real-life setting: a propensity score analysis

BACKGROUND

Urologists may hesitate to offer transurethral resection of the prostate (TURP) because of increased morbidity in elderly patients.

AIMS

We aimed to compare data on postoperative outcomes of elderly men undergoing bipolar transurethral resection of the prostate (B-TURP) as compared to thulium laser vapoenucleation of the prostate (ThuVEP).

METHODS

We retrospectively reviewed data of all patients aged ≥ 75 years who underwent benign prostatic hyperplasia surgery. Differences between interventions were estimated using propensity scores (PS) to adjust for different patients characteristics.

RESULTS

Between 2017 and 2020, 275 men were included in the analysis. Propensity score retrieved 65 patients in each group. Median age was 78 (4) years in B-TURP group and 78 (6) in ThuVEP group. Median prostate volume was 63 (35) ml and 54 (24) ml in B-TURP group and ThuVEP group, respectively. Only American Society of Anesthesiologists score was significantly higher in ThuVEP group (p = 0.006). Median operation time, catheterization time, and hospital stay were similar in both groups (55 min, 2 and 3 days). Overall, 84.6% of men had no complications, with no significant differences between the groups (p = 0.234). Only one patient in B-TURP group experienced a Clavien grade IIIb complication. By 1 year, there were a statistically significant differences in International Prostate Symptom Score (p = 0.000) in favor of B-TURP group and in maximal urine flow rate (p = 0.000) in favor of ThuVEP group.

DISCUSSION AND CONCLUSIONS

Both procedures showed excellent functional improvements one year after surgery with a low rate of major complications in men aged ≥ 75 years with small-to-medium sized prostates.

Trends and Clinical Impact of Gastrointestinal Endoscopic Procedures on Acute Heart Failure in Spain (2002-2017)

Introduction: Heart failure decompensation can be triggered by many factors, including anemia. In cases of iron deficiency anemia or iron deficiency without anemia, endoscopic studies are recommended to rule out the presence of gastrointestinal neoplasms or other associated bleeding lesions. Objectives: The aims of this study were to (i) examine trends in the incidence, clinical characteristics, and in-hospital outcomes of patients hospitalized with heart failure from 2002 to 2017 who underwent esophagogastroduodenoscopy (EGD) and/or colonoscopy, and to (ii) identify factors associated with in-hospital mortality (IHM) among patients with heart failure who underwent an EGD and/or a colonoscopy. Methods: We conducted an observational retrospective epidemiological study using the Spanish National Hospital Discharge Database (SNHDD) between 2002 and 2017. We included hospitalizations of patients with a primary discharge diagnosis of heart failure. Cases were reviewed if there was an ICD-9-CM or ICD-10 procedure code for EGD or colonoscopy in any procedure field. Multivariable logistic regression models were constructed to identify predictors of IHM among HF patients who underwent an EGD or colonoscopy. Results: A total of 51,187 (1.32%) non-surgical patients hospitalized with heart failure underwent an EGD and another 72,076 (1.85%) patients had a colonoscopy during their admission. IHM was significantly higher in those who underwent an EGD than in those who underwent a red blood cell transfusion (OR 1.10; 95%CI 1.04–1.12). However, the use of colonoscopy seems to decrease the probability of IHM (OR 0.45; 95%CI 0.41–0.49). In patients who underwent a colonoscopy, older age seems to increase the probability of IHM. However, EGD was associated with a lower mortality (OR 0.60; 95% CI 0.55–0.64). Conclusion: In our study, a decrease in the number of gastroscopies was observed in relation to colonoscopy in patients with heart failure. The significant ageing of the hospitalized HF population seen over the course of the study could have contributed to this. Both procedures seemed to be associated with lower in-hospital mortality, but in the case of colonoscopy, the risk of in-hospital mortality was higher in elderly patients with heart failure and associated neoplasms. Colonoscopy and EGD seemed not to increase IHM in patients with heart failure.

Comparison of Positive Inotropic Agents in the Management of Acute Decompensated Heart Failure

Current guidelines recommend the consideration of positive inotropes in patients with acute decompensated heart failure (ADHF) who have low cardiac index and evidence of systemic hypoperfusion or congestion. However, there is no evidence detailing the first line agent for the management of ADHF. The purpose of this study was to compare the safety and efficacy of dobutamine to milrinone for the treatment of ADHF. This was a single-center, retrospective study at a tertiary academic medical center, approved by Partner's Health Care Institutional Review Board. Patients included in this study were those admitted with ADHF who received dobutamine or milrinone from June 2015 to July 2017. A total of 95 dobutamine and 40 milrinone patients were included in the analysis. Median hospital length of stay was 12 days in the dobutamine group versus 10 days in the milrinone group (P = 0.34). Rehospitalization within 30 days occurred in 29.5% of patients in the dobutamine group versus 17.5% of patients in the milrinone group (P = 0.15). Median intensive care unit length of stay was 4.5 days in the dobutamine group versus 10 days in the milrinone group (P < 0.01). All other minor end points including all-cause mortality, progression to renal failure within 72 hours, rehospitalization in 90 days, and urine output within 72 hours of therapy were not found to be statistically significant. In addition, a post hoc analysis compared major and minor outcomes between milrinone and dobutamine using linear and logistic regression with adjustment for baseline characteristics. There were not any statistically significant findings in the post hoc analysis. Overall, there were no statistically significant differences in outcomes between the 2 groups other than longer intensive care unit length of stay in the milrinone group.

Congestive Heart Failure and Upper Digestive Endoscopic Lesions

Objective: To evaluate the impact of congestive heart failure and the most important clinical and pathological factors on severe upper digestive mucosal lesions.

Methods: The study included 749 patients referred for upper digestive endoscopy, divided into two groups: 140 subjects with congestive heart failure (study group) and 609 subjects without heart failure (control group).

Results: Severe endoscopic lesions quantified according to Lanza score (OR = 3.84, 95% IC: 2.62-5.62), active/inactive gastritis (OR = 2.07, 95% CI: 1.36-3.14), intestinal metaplasia and/or gastric atrophy (OR = 2.42, 95% CI: 1.67-3.52) were significant more frequent among patients with heart failure. Anemia (OR = 3.65, 95% IC: 2.48-5.37) and all investigated comorbidities, as well as alcohol consumption (OR = 1.60, 95% IC: 1.10-2.34) and smoking (OR = 1.76, 95% IC: 1.17-2.64) were more frequent in the study-group. Dividing the patients with cardiac insufficiency according to the severity of their endoscopic lesions, the male gender (OR = 2.76, 95% IC: 1.35–5.61) and daily low-dose aspirin consumption were found to be more frequent among patients with severe endoscopic lesions (OR = 7.71, 95% IC: 3.62–16.40), while anticoagulant therapy and alcohol consumption were borderline associated with mucosal lesions (p=0.08).

Conclusions: Male patients and aspirin consumers with heart failure, but not those with H. pylori infection seem to be more prone to develop upper digestive endoscopic lesions, while alcohol consumption or anticoagulant therapy could be other modifiable factors associated with severe endoscopic lesions in a congestive gastro-duodenal mucosa.

Effect of the self-management education program on the quality of life in people with chronic heart failure: a randomized controlled trial

Background

Chronic Heart Failure (CHF) is a syndrome that negatively affects a person's Quality of Life (QOL). The efficient self-management education program increases the individual's abilities and skills for following and participating in a long-term healthcare plan.

Objective

The aim of this study was to determine the effect of the self-management education program on QOL in people with CHF.

Methods

This randomized controlled trial study was conducted on 60 people with CHF and without sensory-cognitive problem from April-August 2015. They were selected using the convenience sampling method, and were randomly assigned into the intervention and control groups. The control group received the routine education presented to participants at discharge. However, besides the routine education, the intervention group received the self-management education program consisting of three sessions followed for a 3-month period. The Iranian heart failure QOL questionnaire was used for data collection before and after the intervention. The independent-samples and paired-samples t-tests, Chi-square and Fisher exact tests were used for data analysis via the SPSS v.16 software. P<0.05 was considered statistically significant.

Results

No statistically significant differences were reported between the groups in terms of demographic and clinical characteristics, indicating that they were homogeneous. A statistically significant difference was reported between the two groups after the intervention in terms of the mean changes of total QOL (p<0.001) and its dimensions, including symptoms (p=0.002), social interference (p=0.01), psychological condition (p=0.013), and self-efficacy and knowledge (p<0.001). In addition, an improvement was observed in the total QOL in the intervention group after the education (p<0.001).

Conclusions

According to the results of this study, the self-management education program can be considered an appropriate strategy for improving the QOL in people suffering from CHF by health care providers.

Trial registration

The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the IRCT ID: IRCT2015032021521N1.

Funding

The authors received financial support for the research, authorship, and/or publication of this article from Iran University of Medical Sciences (No: 107/105/94/D, date April 11, 2015).

Predictive Factors of One-Year Mortality in a Cohort of Patients Undergoing Urgent-Start Hemodialysis

Background

Chronic kidney disease (CKD) affects 10–15% of adult population worldwide. Incident patients on hemodialysis, mainly those on urgent-start dialysis at the emergency room, have a high mortality risk, which may reflect the absence of nephrology care. A lack of data exists regarding the influence of baseline factors on the mortality of these patients. The aim of this study was to evaluate the clinical and laboratory characteristics of this population and identify risk factors that contribute to their mortality.

Patients and methods

We studied 424 patients who were admitted to our service between 01/2006 and 12/2012 and were followed for 1 year. We analyzed vascular access, risk factors linked to cardiovascular disease (CVD) and mineral and bone disease associated with CKD (CKD-MBD), and clinical events that occurred during the follow-up period. Factors that influenced patient survival were evaluated by Cox regression analysis.

Results

The patient mean age was 50 ± 18 years, and 58.7% of them were male. Hypertension was the main cause of primary CKD (31.8%). Major risk factors were smoking (19.6%), dyslipidemia (48.8%), and CVD (41%). Upon admission, most patients had no vascular access for hemodialysis (89.4%). Biochemical results showed that most patients were anemic with high C-reactive protein levels, hypocalcemia, hyperphosphatemia, elevated parathyroid hormone and decreased 25-hydroxy vitamin D. At the end of one year, 60 patients died (14.1%). These patients were significantly older, had a lower percentage of arteriovenous fistula in one year, and low levels of 25-hydroxy vitamin D.

Conclusions

The combined evaluation of clinical and biochemical parameters and risk factors revealed that the mortality in urgent-start dialysis is associated with older age and low levels of vitamin D deficiency. A lack of a permanent hemodialysis access after one year was also a risk factor for mortality in this population.