Barbara A. Pisani

Malnutrition and Cachexia in Heart Failure

Heart failure is a growing public health concern. Advanced heart failure is frequently associated with severe muscle wasting, termed cardiac cachexia This process is driven by systemic inflammation and tumor necrosis factor in a manner common to other forms of disease-related wasting seen with cancer or human immunodeficiency virus. A variable degree of malnutrition is often superimposed from poor nutrient intake. Cardiac cachexia significantly decreases quality of life and survival in patients with heart failure. This review outlines the evaluation of nutrition status in heart failure, explores the pathophysiology of cardiac cachexia, and discusses therapeutic interventions targeting wasting in these patients.

Prevention of osteoporosis in cardiac transplant recipients

Osteoporosis is a leading cause of pretransplant and posttransplant morbidity. The need for early detection by measuring bone mineral density, even before transplant, must be emphasized. Preventive measures are not comparable. The use of calcium and vitamin D supplements, although recommended, is inadequate for the prevention of bone loss and complications such as vertebral fractures. Bisphosphonates have been shown to attenuate the bone loss and reduce fractures associated with steroid-induced osteoporosis. Small studies in transplant recipients suggest similar results. Other preventive measures such as hormone replacement therapy are also helpful. There are limited data on the administration of nasal calcitonin in transplant recipients.

Evolution of a Geriatric Syndrome: Pathophysiology and Treatment of Heart Failure with Preserved Ejection Fraction

The majority of older adults who develop heart failure (HF), particularly older women, have a preserved left ventricular ejection fraction (HFpEF). The prevalence of this syndrome is increasing, and the prognosis is not improving, unlike that of HF with reduced ejection fraction (HFrEF). Individuals with HFpEF have severe symptoms of effort intolerance, poor quality of life, frequent hospitalizations, and greater likelihood of death. Despite the importance of HFpEF, there are numerous major gaps in our understanding of its pathophysiology and management. Although it was originally viewed as a disorder due solely to abnormalities in left ventricular diastolic function, our understanding has evolved such that HFpEF is now understood as a systemic syndrome involving multiple organ systems, and it is likely that it is triggered by inflammation and other as‐yet‐unidentified circulating factors, with important contributions of aging and multiple comorbidities, features generally typical of other geriatric syndromes. We present an update on the pathophysiology, diagnosis, management, and future directions in this disorder in older persons.

Use of Therapeutic Plasma Exchange and ECMO Support with Impella for LV Vent as Treatment for Cardiogenic Shock in Acute Thyrotoxicosis/Thyroid Storm

The utility of therapeutic plasma exchange (TPE) in acute thyrotoxicosis refractory to conventional therapy has been documented in case study literature. TPE has been shown to remove T3 and T4 bound to albumin, autoantibodies, catecholamines, and cytokines in patients with thyrotoxicosis. In clinical practice, TPE has been used as a treatment in refractory cases of acute thyrotoxicosis and as a bridge for those patients needing surgical treatment. At present, TPE is listed as an ASFA category III indication for thyrotoxicosis. We present a case of acute thyrotoxicosis and cardiogenic shock responsive to early TPE. A 27-year-old lady presented to our emergency department with dyspnea, nausea, and vomiting. She was found to be in atrial fibrillation with rapid ventricular response, hypotensive, and in acute respiratory distress requiring intubation. Her TSH was undetectable and her clinical condition rapidly declined. She developed acute cardiogenic shock (LVEF

Delayed Drive Line Site Soft Tissue Infection after Ventricular Assis Device Inactivation: A Case Report

Introduction Heart transplantation is the treatment of choice for many patients with end-stage heart failure (HF). However, organ donor supply is limited. Ventricular assist devices (VAD) are increasingly used for the management of HF as a bridge to transplantation (BTT) or destination therapy (DT). Some patients with VADs have partial or full recovery of LV function thus qualifying for explant. Other patients may require an explant/exchange or pump inactivation due to complications of the device. While the infections at drive line site with active LVADs are seen in practice, we present a case of a delayed skin infection at the site of the original drive line. Case Report A 45-year-old man with ischemic cardiomyopathy underwent HeartMate II implant in 2014 as BTT. His subsequent course was complicated by recurrent GI bleeding (GIB). He was admitted in 2016 with GIB and declined further use of Coumadin. He was maintained on ASA but had recurrent bleeding. During these admissions he decided that he was not interested in heart transplantation. He was removed from the UNOS waitlist and his status was switched to VAD as DT. He was readmitted with VAD stoppage, low flows, high powers and chocolate colored urine. LDH>1500 and decreased hemoglobin. He was a poor surgical candidate, declined anticoagulation .He had minimal myocardial recovery with persistent severe LV dysfunction (EF ∼ 10%). He was felt to be too ill to undergo VAD explant surgery. Thus, the VAD was deactivated, inflow cannula and outflow grafts left in situ and the drive line severed and surgically buried. A ∼10-12 cm remnant was buried under the skin (figure). Skin incision was closed primarily. The original exit site was left to heal by secondary intention. The wound completely healed. Luckily, patient continued to do well. Almost a year after VAD inactivation, he developed skin irritation at the site of prior driveline site. He delayed contacting us and presented to clinic with a severe soft tissue infection (Enterobacter cloacae and Staph aureus) at the old driveline site. He required surgical debridement, excision of the driveline, IV antibiotics and a wound-vac. The drive line site is healing well afterwards. Discussion One sees a drive line site infection in VAD patients, but our case highlights the fact that even if the drive line has been excised and stump buried under the skin, a delayed infection like ours, though unlikely, is still possible.Our case also highlights the fact that leaving all the VAD apparatus in patients who are high risk for explant is a safe option, as our patient continues to do well a year after his VAD deactivation.

Size matching in heart transplantation donor selection: "Too big to fail"?

Donor selection in heart transplant remains a complex and controversial topic, with most of the recommendations based on consensus of opinion. Given the shortage of available donor hearts and declining utilization rates, coupled with the still significant risk of early graft failure, effective matching of donor to recipient remains crucial. Despite disagreement about the allowable degree of mismatch, recipients with significantly undersized donors demonstrate higher mortality. The most recent International Society for Heart and Lung Transplantation (ISHLT) guidelines recommend a donor within 30% of recipient weight (20% if female donor/male recipient). Further, the guidelines suggest than male donors 470 kg may be used for virtually all recipients, although they do not specify whether this includes obese donors. Still, donor size/weight mismatch remains a frequent reason donor hearts are declined. Data on donor refusal based on size/weight with or without other reasons for refusal are not readily available. The same refusal code is used for donors too large or small and weight-incompatible with potential recipients. Thus, accurate data on how frequently donors are declined for height/weight mismatch may be overor underestimated. In this issue of the journal, Bergenfeldt and colleagues address the important question of matching donor to recipient in an era of steadily increasing obesity. Using data from the ISHLT, they examined the interaction between obese and non-obese heart transplant recipients and weight difference from their eventual donors. They demonstrated that, in non-obese recipients (defined as body mass index [BMI] o30 kg/m), a weight difference of 430% was associated with decreased survival at 30 days, 1 year and 5 years. However, if the recipient was obese, a 430% weight difference did not portend increased mortality For completeness, they included underweight recipients, but those patients so rarely receive an organ from an undersized donor that firm conclusions could not be drawn about this group.