Eric Nellessen

Myocardial contractile reserve during exercise predicts left ventricular reverse remodelling after cardiac resynchronization therapy

AIMS Lack of response to cardiac resynchronization therapy (CRT) may be due to the presence of significant amount of scar or fibrotic tissue at myocardial level. This study sought to investigate the potential impact of myocardial contractile reserve as assessed during exercise echocardiography on left ventricular (LV) reverse remodelling (decrease in LV end-systolic volume > or =15% after 6 months of CRT). METHODS AND RESULTS Fifty-one consecutive patients with heart failure underwent exercise Doppler echocardiography before CRT implantation to assess global contractile reserve and local contractile reserve (assessed by two-dimensional speckle tracking) in the region of the LV pacing lead. Responders (30 patients) showed a greater exercise-induced increase in left ventricular ejection fraction (LVEF) compared with non-responders (P < 0.001). Contractile reserve was directly related to the improvement in LVEF and to LV reverse remodelling after 6 months of CRT (P < 0.001). A 6.5% exercise-induced increase in LVEF yielded a sensitivity of 90% and a specificity of 85.7% to predict the response after 6 months of CRT. Baseline myocardial deformation as well as contractile reserve in the LV pacing lead region was greater in responders than in non-responders (P < 0.0001). CONCLUSION Myocardial contractile reserve (global and regional) is a strong predictive factor of LV reverse remodelling after CRT.

Impact of contractile reserve on acute response to cardiac resynchronization therapy

BackgroundCardiac resynchronization therapy (CRT) provides benefit for congestive heart failure, but still 30% of patients failed to respond to such therapy. This lack of response may be due to the presence of significant amount of scar or fibrotic tissue at myocardial level. This study sought to investigate the potential impact of myocardial contractile reserve as assessed during exercise echocardiography on acute response following CRT implantation.MethodsFifty-one consecutive patients with heart failure (LV ejection fraction 27% ± 5%, 67% ischemic cardiomyopathy) underwent exercise Doppler echocardiography before CRT implantation to assess global contractile reserve (improvement in LV ejection fraction) and local contractile reserve in the region of the LV pacing lead (assessed by radial strain using speckle tracking analysis). Responders were defined by an increase in stroke volume ≥ 15% after CRT.ResultsCompared with nonresponders, responders (25 patients) showed a greater exercise-induced increase in LV ejection fraction, a higher degree of mitral regurgitation and a significant extent of LV dyssynchrony. The presence of contractile reserve was directly related to the acute increase in stroke volume (r = 0.48, p < 0.001). Baseline myocardial deformation as well as contractile reserve in the LV pacing lead region was greater in responders during exercise than in nonresponders (p < 0.0001).ConclusionThe present study showed that response to CRT largely depends not only on the extent of LV dyssynchrony and the severity of mitral regurgitation but also on the presence of contractile reserve.

What is the potential increase in the heart graft pool by cardiac donation after circulatory death

Heart transplantation remains the only definite treatment option for end‐stage heart diseases. The use of hearts procured after donation after circulatory death (DCD) could help decrease the heart graft shortage. The aim of this study was to evaluate the potential increase in heart graft pool by developing DCD heart transplantation. We retrospectively reviewed our local donor database from 2006 to 2011, and screened the complete controlled DCD donor population for potential heart donors, using the same criteria as for donation after brain death (DBD) heart transplantation. Acceptable donation warm ischemic time (DWIT) was limited to 30 min. During this period 177 DBD and 70 DCD were performed. From the 177 DBD, a total of 70 (39.5%) hearts were procured and transplanted. Of the 70 DCD, eight (11%) donors fulfilled the criteria for heart procurement with a DWIT of under 30 min. Within the same period, 82 patients were newly listed for heart transplantation, of which 53 were transplanted, 20 died or were unlisted, and 9 were waiting. It could be estimated that 11% of the DCD might be heart donors, representing a 15% increase in heart transplant activity, as well as potential reduction in the deaths on the waiting list by 40%.

Creatinine-based formulae for the estimation of glomerular filtration rate in heart transplant recipients

Abstract:  Chronic renal failure (CRF) is a common complication in heart transplant patients. Serum creatinine has clear limitations for the detection and estimation of glomerular filtration rate (GFR). Various creatinine‐based formulae are classically used for GFR estimation, but little scientific evidence exists for such use in a heart transplant population. GFR was measured using the plasmatic clearance of the glomerular tracer 51Cr‐EDTA in 27 heart transplant patients with two measures for 22 of the patients. Forty‐nine measures were thus available for analysis. The precision and accuracy (Bland and Altman analysis) of the Cockcroft, simplified Modified Diet in Renal Diseases (MDRD) and new Mayo Clinic formulae were compared. The mean GFR of the population was 39 ± 15 mL/min/1.73 m2. All formulae were well correlated with the GFR. With the Bland and Altman analysis, the accuracy of the MDRD formula appeared higher than that of the Cockcroft or the Mayo Clinic formulae (bias of +12 mL/min/1.73 m2, vs. +19.9 mL/min/1.73 m2, and +22.1 mL/min/1.73 m2, respectively). The difference between the estimated and measured GFR was higher than 20 mL/min/1.73 m2 in 51% and 55% cases when using the Cockcroft and the Mayo Clinic formulae respectively, whereas the difference was only noted in 14% cases when the MDRD was used. Among creatinine‐based formulae, the MDRD appears the most precise and accurate for estimating the GFR in heart transplant patients. However, when the GFR must be measured with high accuracy, we recommend the use of a reference method like inulin or 51Cr‐EDTA plasma clearance techniques.

Surgical treatment of cardiovascular complications in patients with Marfan syndrome: a report of two cases and literature review.

Abstract Cardiovascular disease is the main cause of morbidity and mortality in patients with Marfan syndrome. The most life threatening complication is aortic root aneurysms leading to aortic dissection or rupture. It can be prevented by regular aortic follow-up and prophylactic aortic surgery. Modern aortic surgery has led to a substantial increase in the life expectancy of these patients. We report two cases of Marfan syndrome with cardiovascular complications. Their management is discussed according to the most recent literature.

Noncomplicated large complex tear in an aneurysmal Marfan ascending aorta.

1 24-year-old man in New York Heart Association functional class 4 with proven Marfan syndrome (family istory) was scheduled for cardiac transplantation because of nd-stage biventricular failure on long-standing massive aoric regurgitation. A preoperative contrast enhanced computed omographic scan revealed a dilatation of the aortic root and a iameter of the proximal ascending aorta of 65 mm without igns of chronic or acute dissection (Fig 1). Cardiac transplantation was carried out 4 months later. In he meantime, the patient did not experience any chest ain. Cardiopulmonary bypass was established between he left femoral artery and the right atrium. After induced brillation, the cross clamp was placed tangentially at the evel of the emergence of the brachiocephalic trunk. Cardiectomy and resection of the whole ascending aorta as performed. Examination disclosed a large (27 mm) comlex tear in the right anterolateral concavity of the ascending orta, starting just above the noncoronary sinus (Fig 2). There as no associated sign of dissection or fissuration of the scending aorta recognizable by external inspection or after