Category Archives: Cardiology

Posted by
Posted in

Surgical options after Fontan failure

Objective

The objective of this European multicenter study was to report surgical outcomes of Fontan takedown, Fontan conversion and heart transplantation (HTX) for failing Fontan patients in terms of all-cause mortality and (re-)HTX.

Methods

A retrospective international study was conducted by the European Congenital Heart Surgeons Association among 22 member centres. Outcome of surgery to address failing Fontan was collected in 225 patients among which were patients with Fontan takedown (n=38; 17%), Fontan conversion (n=137; 61%) or HTX (n=50; 22%).

Results

The most prevalent indication for failing Fontan surgery was arrhythmia (43.6%), but indications differed across the surgical groups (p<0.001). Fontan takedown was mostly performed in the early postoperative phase after Fontan completion, while Fontan conversion and HTX were mainly treatment options for late failure. Early (30 days) mortality was high for Fontan takedown (ie, 26%). Median follow-up was 5.9 years (range 0–23.7 years). The combined end point mortality/HTX was reached in 44.7% of the Fontan takedown patients, in 26.3% of the Fontan conversion patients and in 34.0% of the HTX patients, respectively (log rank p=0.08). Survival analysis showed no difference between Fontan conversion and HTX (p=0.13), but their ventricular function differed significantly. In patients who underwent Fontan conversion or HTX ventricular systolic dysfunction appeared to be the strongest predictor of mortality or (re-)HTX. Patients with valveless atriopulmonary connection (APC) take more advantage of Fontan conversion than patients with a valve-containing APC (p=0.04).

Conclusions

Takedown surgery for failing Fontan is mostly performed in the early postoperative phase, with a high risk of mortality. There is no difference in survival after Fontan conversion or HTX.

Posted by
Posted in

Rescuing the failing Fontan

Dr van Melle and associates from the European Congenital Heart Surgeons Association (ECHSA) are to be congratulated on their multicenter study on the treatment of failed Fontan patients.1 With the Fontan operation now being 40 years old surgeons are seeing the full spectrum of Fontan circulation failures.2 Strategies (and outcomes) for treating these patients are critically important and the review from the ECHSA is very timely and helpful. The authors have divided the failed Fontan patients into three groups: those undergoing Fontan takedown early after the Fontan operation, those undergoing the Fontan conversion procedure, and those undergoing heart transplantation. These are all critically ill patients with high mortality rates in all three groups. A summary of their results is shown in table 1 (Results of Surgical Intervention for the failing Fontan).1 The immediate conclusion looking at these numbers is that all of…

Posted by
Posted in

Serial galectin-3 and future cardiovascular disease in the general population

Background

Lifetime risk for cardiovascular (CV) disease is high but predicting incident events on an individual level remains difficult. Single measurements of galectin-3, a marker of tissue fibrosis, predict mortality and new-onset heart failure (HF). Persistently elevated levels may indicate a clinically silent disease process.

Objectives

Our aim was to establish the value of serial galectin-3 measurements to predict CV outcomes in the general population.

Methods

Plasma galectin-3 was measured in the Prevention of REnal and Vascular ENd-stage Disease (PREVEND) study at baseline and after ~4 years. Changes in serial galectin-3 were expressed as categorical changes or absolute change from baseline and were related to subsequent outcome.

Results

Serial galectin-3 was measured in 5958 subjects (mean age 49±12 years; 49% female). The median duration of follow-up was 8.3 years. Persistently elevated galectin-3 (defined as highest quartile at baseline and highest quartile during visit 2, n=757 subjects) was associated with a higher risk for new-onset HF, CV mortality, all-cause mortality, new-onset atrial fibrillation and CV events, compared with subjects with non-persistently elevated galectin-3. After multivariable adjustments for baseline characteristics, serial galectin-3 remained an independent predictor of new-onset HF (HR 1.85 (1.10–3.13); p=0.02) but not for other outcomes. Serial measurements provided more accurate prognostic value to predict new-onset HF, compared with a single baseline measurement (Harrell’s C: 0.72 (0.68–0.75) vs 0.68 (0.65–0.72); p=0.002, respectively) with significant net reclassification.

Conclusions

Persistently elevated galectin-3 predicts new-onset HF after adjustment for covariates, and serial measurements provide more accurate prognostic information compared with single determination of galectin-3. This may help to identify individuals who are at risk for incident HF and might provide a measure to monitor interventions.

Posted by
Posted in

Homeward Bound, not hospital rebound: how transitional palliative care can reduce readmission

Despite therapeutic advances in the management of heart failure (HF), approximately 25% of hospitalised patients with HF are readmitted within 30 days.1 These costly episodes of care have given rise to numerous policy initiatives, such as the Medicare Hospital Readmissions Reduction Programme which fiscally penalises hospitals with ‘excess’ readmissions.2

Transitional care programmes have emerged as a potential solution to avert HF readmissions by monitoring and supporting patients and caregivers for a limited period of time post-discharge. A recent meta-analysis of these interventions suggests that programmes which incorporate home visits are effective at reducing all-cause readmission and mortality, whereas less-intensive programmes of structured telephone support alone can reduce HF-related readmissions and mortality.3

In their Heart publication, Wong et al report the findings from their pilot trial of a transitional palliative care programme for patients with end-stage HF (TPC-ESHF).4 They demonstrate that patients randomised…

Posted by
Posted in

Gender differences in coronary heart disease

Learning objectives

  • Curriculum sections: 2.8 (Acute Coronary Syndromes) and 2.9 (Chronic Ischaemic Heart disease).

  • Learning objectives: outline the differences in the presentation patterns, clinical characteristics, behavioural characteristics and clinical outcomes relating to gender and coronary heart disease (CHD). This will incorporate the following:

  • Knowledge: understand the benefit of cardiovascular interventions in women in comparison with men in both the acute and chronic presentations of CHD. Delineate the data reflecting the need for more research into women and heart disease, coupled with more patient and physician education.

  • Skills: learn the presentation patterns and gender-specific issues related to patients presenting with CHD.

  • Behaviours and attitudes: discuss the preconceived ideas around gender and heart disease, emphasising the need for enhanced assessment of women with heart disease.

  • Introduction

    The importance of coronary heart disease (CHD) as a disease of both genders tends to be underappreciated,…

    Posted by
    Posted in

    The Fontan circulation after 45 years: update in physiology

    The Fontan operation was first performed in 1968. Since then, this operation has been performed on thousands of patients worldwide. Results vary from very good for many decades to very bad with a pleiad of complications and early death. A good understanding of the physiology is necessary to further improve results. The Fontan connection creates a critical bottleneck with obligatory upstream congestion and downstream decreased flow; these two features are the basic cause of the majority of the physiologic impairments of this circulation. The ventricle, while still the engine of the circuit, cannot compensate for the major flow restriction of the Fontan bottleneck: the suction required to compensate for the barrier effect cannot be generated, specifically not in a deprived heart. Except for some extreme situations, the heart therefore no longer controls cardiac output nor can it significantly alter the degree of systemic venous congestion. Adequate growth and development of the pulmonary arteries is extremely important as pulmonary vascular impedance will become the major determinant of Fontan outcome. Key features of the Fontan ventricle are early volume overload and overgrowth, but currently chronic preload deprivation with increasing filling pressures. A functional decline of the Fontan circuit is expected and observed as pulmonary vascular resistance and ventricular filling pressure increase with time. Treatment strategies will only be successful if they open up or bypass the critical bottleneck or act on immediate surroundings (impedance of the Fontan neoportal system, fenestration, enhanced ventricular suction).

    Posted by
    Posted in

    Dennis Michael Krikler 1928-2016

    When Dennis Krikler completed his term of office as Editor of the British Heart Journal in 1992 the succeeding Editor, Professor Mike Davies, commissioned a Festscrift to acknowledge the achievements of his predecessor who had been at the helm of the journal for 11 years. The contents are a fascinating glimpse of the man, some of his cardiological achievements, certainly his wide-ranging interests and assuredly his international friendships. It is almost certainly the only time that the British Heart Journal has published an article entirely in French, a monologue by Phillipe Coumel who was one of the most original thinkers of modern arrhythmology and a scientific collaborator with Dennis.

    Dennis Krikler was born in 1928 in South Africa. Most of his lifetime interests—cultural, medical, scientific, historical, and photographic—were rooted in the rich world of his childhood in the seaside resort of Muizenberg outside Cape Town where he lived for his…

    Posted by
    Posted in

    Distinguishing ventricular septal bulge versus hypertrophic cardiomyopathy in the elderly

    The burgeoning evidence of patients diagnosed with sigmoidal hypertrophic cardiomyopathy (HCM) later in life has revived the quest for distinctive features that may help discriminate it from more benign forms of isolated septal hypertrophy often labelled ventricular septal bulge (VSB). HCM is diagnosed less frequently than VSB at older ages, with a reversed female predominance. Most patients diagnosed with HCM at older ages suffer from hypertension, similar to those with VSB. A positive family history of HCM and/or sudden cardiac death and the presence of exertional symptoms usually support HCM, though they are less likely in older patients with HCM, and poorly investigated in individuals with VSB. A more severe hypertrophy and the presence of left ventricular outflow obstruction are considered diagnostic of HCM, though stress echocardiography has not been consistently used in VSB. Mitral annulus calcification is very prevalent in both conditions, whereas a restrictive filling pattern is found in a minority of older patients with HCM. Genetic testing has low applicability in this differential diagnosis at the current time, given that a causative mutation is found in less than 10% of elderly patients with suspected HCM. Emerging imaging modalities that allow non-invasive detection of myocardial fibrosis and disarray may help, but have not been fully investigated. Nonetheless, there remains a considerable morphological overlap between the two conditions. Comprehensive studies, particularly imaging based, are warranted to offer a more evidence-based approach to elderly patients with focal septal thickening.

    Posted by
    Posted in

    Sexual activity and concerns in people with coronary heart disease from a population-based study

    Objective

    Sexual activity is a central component of intimate relationships, but sexual function may be impaired by coronary heart disease (CHD). There have been few representative population-based comparisons of sexual behaviour and concerns in people with and without CHD. We therefore investigated these issues in a large nationally representative sample of older people.

    Methods

    We analysed cross-sectional data from 2979 men and 3711 women aged 50 and older from the English Longitudinal Study of Ageing. Sexual behaviour and concerns were assessed by validated self-completion questionnaire and analyses were weighted for non-response. Covariates included age, partnerships status and comorbidities.

    Results

    There were 376 men and 279 women with CHD. Men with CHD were less likely to be sexually active (68.7% vs 80.0%, adjusted OR 0.62, 95% CI 0.47 to 0.81), thought less about sex (74.7% vs 81.9%, OR 0.72, CI 0.54 to 0.95), and reported more erectile difficulties (47.4% vs 38.1%, OR 1.46, CI 1.10 to 1.93) than men without CHD. Effects were more pronounced among those diagnosed within the past 4 years. Women diagnosed <4 years ago were also less likely to be sexually active (35.4% vs 55.6%, OR 0.44, CI 0.23 to 0.84). There were few differences in concerns about sexual activity. Cardiovascular medication showed weak associations with erectile dysfunction.

    Conclusions

    There is an association between CHD and sexual activity, particularly among men, but the impact of CHD is limited. More effective advice after diagnosis might reverse the reduction in sexual activity, leading to improved quality of life.

    Posted by
    Posted in

    Effects of a transitional palliative care model on patients with end-stage heart failure: a randomised controlled trial

    Objective

    To examine the effects of home-based transitional palliative care for patients with end-stage heart failure (ESHF) after hospital discharge.

    Methods

    This was a randomised controlled trial conducted in three hospitals in Hong Kong. The recruited subjects were patients with ESHF who had been discharged home from hospitals and referred for palliative service, and who met the specified inclusion criteria. The interventions consisted of weekly home visits/telephone calls in the first 4 weeks then monthly follow-up, provided by a nurse case manager supported by a multidisciplinary team. The primary outcome measures were any readmission and count of readmissions within 4 and 12 weeks after index discharge, compared using 2 tests and Poisson regression, respectively. Secondarily, change in symptoms over time between control and intervention groups were evaluated using generalised estimating equation analyses of data collected using the Edmonton Symptom Assessment Scale (ESAS).

    Results

    The intervention group (n=43) had a significantly lower readmission rate than the control group (n=41) at 12 weeks (intervention 33.6% vs control 61.0% 2=6.8, p=0.009). The mean number (SE) of readmissions for the intervention and control groups was, respectively, 0.42 (0.10) and 1.10 (0.16) and the difference was significant (p=0.001). The relative risk (CI) for 12-week readmissions for the intervention group was 0.55 (0.35 to 0.88). There was no significant difference in readmissions between groups at 4 weeks. However, when compared with the control group, the intervention group experienced significantly higher clinical improvement in depression (45.9% vs 16.1%, p<0.05), dyspnoea (62.2% vs 29.0%, p<0.05) and total ESAS score (73.0% vs 41.4%, p<0.05) at 4 weeks. There were significant differences between groups in changes over time in quality of life (QOL) measured by McGill QOL (p<0.05) and chronic HF (p<0.01) questionnaires.

    Conclusions

    This study provides evidence of the effectiveness of a postdischarge transitional care palliative programme in reducing readmissions and improving symptom control among patients with ESHF.

    Trial registration number

    HKCTR-1562; Results.

    All Posts from This Category