New strategies for the management of acute decompensated heart failure

Do Patients in Congestive Cardiac Failure Undergoing Cardiac Surgery Demonstrate Worse Outcomes Compared with Those with a History of Cardiac Failure?

<p><b>Objectives:</b> Cardiac surgery in patients with symptoms of congestive cardiac failure (CCF) carries a significant risk of mortality and morbidity. Except for emergencies and in unstable cases, the recommendation has been to delay the operation until the patient is fully recovered. The objective of this study was to determine the consequences of cardiac surgery in patients with acute decompensated heart failure and to compare their outcomes with the results of the operation in patients with previous CCF.</p><p><b>Methods:</b> We compared the outcomes of patients with CCF (n = 707) at the time of cardiac surgery (valve replacement or coronary artery bypass grafting [CABG]) with those with a history of CCF (n = 1583). The EuroSCORE was significantly higher in CCF patients (<i>P</i> < .001). Impaired renal function was also more commonly observed in patients with CCF (<i>P</i> < .001). After adjusting for preoperative characteristics, we compared the 2 groups with respect to postoperative complications, postoperative creatine kinase MB values, and in-hospital mortality.</p><p><b>Results:</b> Before adjusting for preoperative characteristics, we found that in-hospital mortality (15.5%) and postoperative complications, such as arrhythmias (31%), renal failure (19%), stroke (4.7%), and myocardial infarction (MI) (3%), were significantly higher in the CCF group than in those with a previous history of CCF. When the patients were matched for preoperative characteristics, the rates of postoperative MI and arrhythmia were the main complications that were significantly higher in the CCF group, compared with the patients with previous CCF. The 2 groups were not significantly different with respect to in-hospital mortality. The results were not affected by the type of procedure (valve or CABG), and the main factor influencing mortality was the EuroSCORE.</p><p><b>Conclusion:</b> Despite the significant risk of mortality and morbidity in patients with current CCF, cardiac surgery to reverse the cause should not be delayed in these patients, because doing so may lead to further deterioration. Other risk factors, however, should be taken into consideration on an individual basis.</p>

Functional identification of the alveolar edema reabsorption activity of murine tumor necrosis factor-alpha

Tumor necrosis factor-alpha (TNF-alpha) activates sodium channels in Type II alveolar epithelial cells, an important mechanism for the reported fluid resorption capacity of the cytokine. Both TNF-alpha receptor-dependent and -independent effects were proposed for this activity in vitro, the latter mechanism mediated by the lectin-like domain of the molecule. In this study, the relative contribution of the receptor-dependent versus receptor-independent activities was investigated in an in situ mouse lung model and an ex vivo rat lung model. Fluid resorption due to murine TNF-alpha (mTNF-alpha) was functional in mice that were genetically deficient in both types of mTNF-alpha receptor, establishing the importance of mTNF-alpha receptor-independent effects in this species. In addition, we assessed the capacity of an mTNF-alpha-derived peptide (mLtip), which activates sodium transport by a receptor-independent mechanism, to reduce lung water content in an isolated, ventilated, autologous blood-perfused rat lung model. The results show that in this model, mLtip, in contrast to mTNF-alpha, produced a progressive recovery of dynamic lung compliance and airway resistance after alveolar flooding. There was also a significant reduction in lung water. These results indicate that the receptor-independent lectin-like domain of mTNF-alpha has a potential physiological role in the resolution of alveolar edema in rats and mice.

Patient selection for assist devices: bridge to transplant

Patients in severely progressed states of heart failure can be bridged to successful heart transplantation with mechanical assist devices. Experience has demonstrated that patient selection and timing of device implantation are crucial for obtaining acceptable results when using this expensive technology. The degree of irreversible secondary organ dysfunction before re-establishing adequate cardiac output determines the chance of reaching transplantation. Patients who recover during support from all sequelae of end stage heart failure have an excellent outcome after heart transplantation.

Combination of continuous renal replacement therapies (CRRT) and extracorporeal membrane oxygenation (ECMO) for advanced cardiac patients

BACKGROUND

The critically ill patients may require mechanical ventilation, cardiac mechanical support, and other types of critical support. Extracorporeal membrane oxygenation (ECMO) is a supportive therapy, which provides good cardiopulmonary and end-organ support. Continuous renal replacement therapies (CRRT) exhibit important advantages in terms of clinical tolerance and blood purification. This investigation aims to evaluate the acute renal failure in cardiac patients under ECMO, and assess the effect of combining these two technologies, ECMO and CRRT.

METHODS

Between December 1998 and June 2001, 10 adult cardiac patients were treated on ECMO. Five of them were treated with both ECMO and CRRT. The clinical outcomes were retrospectively analyzed.

RESULTS

Of the 10 patients studied, five were men and five were women. The mean age of survivors and non-survivors was 37.00 +/- 14.54 years and 46.17 +/- 7.41 years, respectively. The overall mortality rate was 60%. Survivors did not differ significantly from non-survivors in age or gender. The APACHE II scores on the first day of ECMO support between survival and non-survival were 19.00 +/- 9.38 and 24.67 +/- 3.50 (P value = 0.392) (Table 2), which demonstrates no significant differences too. The cause of death in most patients was related to organ system failure during the 24 h immediately before ECMO started. Five patients with acute renal failure treated by CRRT were eventually died. The median and mean survival in this group on CRRT was 40.50 +/- 18.07 h and 92.60 +/- 60.50 h.

CONCLUSION

We conclude that mortality rate for acute renal failure in cardiac patients under ECMO continues to be high. Our data suggest that acute renal failure is generally a part of multiorgan failure. This unique form of acute renal failure, causes generalized edema and fluid overload despite still low serum creatinine and azotemia, and deteriorates rapidly to death. From this study shows, advanced cardiac failure may need more aggressive and early initiation of ECMO support before acute renal failure develops. Acute renal failure in advanced heart failure under ECMO support means a grave sign, need aggressive heart transplantation therapy as soon as possible. Combination of CRRT and ECMO might serve an alternative therapy bridging the temporary replacement treatment and heart transplantation in advanced cardiac patients.