Jonathan Cousins

The effect of bariatric surgery on echocardiographic indices: a review of the literature

Obesity is the new epidemic and is associated with an increased risk of diastolic and systolic heart failure. Effective treatment options with drastic results such as bariatric surgery have raised interest in the possible reversal of some of the cardiovascular sequelae. Many studies have assessed individually the effect of weight loss on specific echocardiographic indices, mostly employing nonhomogeneous groups. The purpose of this narrative review is to summarise the effect of bariatric surgery on echocardiographic indices of biventricular function and to help in the understanding of the expected echocardiographic changes in bariatric patients after weight‐loss surgery

Influence of gender on clinical outcomes following transcatheter aortic valve implantation from the UK transcatheter aortic valve implantation registry and the National Institute for Cardiovascular Outcomes Research.

Gender differences exist in outcomes after percutaneous coronary intervention and coronary artery bypass graft surgery but have yet to be fully explored after transcatheter aortic valve implantation. We aimed to investigate gender differences after transcatheter aortic valve implantation in the UK National Institute for Cardiovascular Outcomes Research registry. A retrospective analysis was performed of Medtronic CoreValve and Edwards SAPIEN implantation in 1,627 patients (756 women) from January 2007 to December 2010. Men had more risk factors: poor left ventricular systolic function (11.9% vs 5.5%, p <0.001), 3-vessel disease (19.4% vs 9.2%, p <0.001), previous myocardial infarction (29.5% vs 13.0%, p <0.001), peripheral vascular disease (32.4% vs 23.3%, p <0.001), and higher logistic EuroSCORE (21.8 ± 14.2% vs 21.0 ± 13.4%, p = 0.046). Thirty-day mortality was 6.3% (confidence interval 4.3% to 7.9%) in women and 7.4% (5.6% to 9.2%) in men and at 1 year, 21.9% (18.7% to 25.1%) and 22.4% (19.4% to 25.4%), respectively. There was no mortality difference: p = 0.331 by log-rank test; hazard ratio for women 0.91 (0.75 to 1.10). Procedural success (96.6% in women vs 96.4% in men, p = 0.889) and 30-day cerebrovascular event rates (3.8% vs 3.7%, p = 0.962) did not differ. Women had more major vascular complications (7.5% vs 4.2%, p = 0.004) and less moderate or severe postprocedural aortic regurgitation (7.5% vs 12.5%, p = 0.001). In conclusion, despite a higher risk profile in men, there was no gender-related mortality difference; however, women had more major vascular complications and less postprocedural moderate or severe aortic regurgitation.

Ventricular remodelling post-bariatric surgery: is the type of surgery relevant? A prospective study with 3D speckle tracking

AIMS The aim of the study was to examine ventricular remodelling in patients free of cardiac risk factors, before, and 6 months post-bariatric surgery with the new imaging modality of three-dimensional (3D) strain and the comparison of two surgical techniques: sleeve gastrectomy vs. gastric bypass. METHODS AND RESULTS Fifty-two consecutive patients referred to the Bariatric Services of Imperial College NHS Trust were examined with conventional 2D and 3D strain echocardiography, prior to and 6 months after bariatric surgery. They were all free from cardiac disease. The study cohorts mean age was 44.2 ± 8.7 years and body mass index of 42.4 ± 4.6 g/m(2) prior to surgery. Eighteen patients (34.6%) underwent laparoscopic sleeve gastrectomy, and 34 laparoscopic gastric bypass. On 3D speckle tracking, there was significant reverse remodelling post-bariatric surgery [left ventricular (LV) ejection fraction (EF): pre-surgery: 59 ± 8% vs. post-surgery: 67 ± 7%, P < 0.001 and right ventricular (RV) EF: pre-surgery: 60 ± 9% vs. post-surgery: 68 ± 8.2%, P = 0.0001]. Furthermore, there was significant regression of mass (LV mass: pre-surgery: 111 ± 23.5 g vs. post-surgery: 92.8 ± 15.5 g and RV mass: pre-surgery: 95.2 ± 19.8 vs. post-surgery: 67.3 ± 16.3, P < 0.001). RV and LV global strain improved 6 months post-bariatric surgery: global RV strain: pre-surgery -11.7 ± 4 vs. post-surgery -17.52 ± 3.7, P < 0.001; global LV strain: pre-surgery: -20.2 ± 1.7 vs. post-surgery: -26.5 ± 1.86, P < 0.001. Sleeve gastrectomy and gastric bypass had comparable effects. CONCLUSION Bariatric surgery has an important effect in reverse LV and RV remodelling and it substantially improves RV longitudinal strain.

The use of high-dose intrathecal diamorphine in laparoscopic bariatric surgery: a single-centre retrospective cohort study

Introduction: The use of intrathecal diamorphine is not commonplace in laparoscopic bariatric surgery. At our institution, a major UK bariatric centre, high-dose intrathecal diamorphine is routinely utilised. Methods: Data were analysed retrospectively. Fifty-three patients who had a spinal anaesthetic were matched against age, sex, body mass index and surgical procedure type to generate controls. Pain scores were recorded in the post-anaesthetic care unit on arrival, after 1 hour and on discharge to the ward. Post-operative nausea and vomiting; post-operative hypertension; pruritus; 24-hour morphine consumption and length of stay were measured. Results: Pain scores were better in the spinal anaesthetic group in all measured categories (p = 0.033, p < 0.01, p < 0.01); post-operative nausea and vomiting was less common in the spinal anaesthetic group (p < 0.01); post-operative hypertension was less common in the spinal anaesthetic group (p = 0.25); pruritus was more common in the spinal anaesthetic group (p < 0.01); morphine consumption was less common in the spinal anaesthetic group (p = 0.037). Length of hospital stay was reduced by 12.4 hours (p = 0.025). Conclusion: We propose that this is a practical and safe technique to adopt. A randomised-control trial will need to be conducted in order to find the most efficacious volume of local anaesthetic and dose of diamorphine

Anaesthetic Preparation of Obese Patients: Current Status on Optimal Work-up

Purpose of ReviewWith the prevalence of obesity rapidly growing, bariatric anaesthesia becomes everyday anaesthesia rather than a subspecialty. In this review, we are aiming to draw attention to this complex group of patients and their comorbidities, relevant to everyday practice for contemporary anaesthetists.Recent FindingsWe wanted to focus greatly on sleep-related breathing disorders, because preoperative screening, diagnosis and treatment of the aforementioned make a huge impact in the improvement of preoperative morbidity and mortality, including positive effects on the cardiovascular system. The overview is touching on main obesity-related comorbidities and guides the anaesthetist and associated health professionals on how to approach and manage them.SummaryA multidisciplinary approach widely used in bariatric care may be adopted in the care of obese patients in order to reduce preoperative morbidity and mortality. We advocate the early involvement of the anaesthetic team in the preoperative assessment of obese patients in order to achieve appropriate risk stratification and optimise the care.

Impact of clinical and procedural factors upon C reactive protein dynamics following transcatheter aortic valve implantation.

AIM To determine the effect of procedural and clinical factors upon C reactive protein (CRP) dynamics following transcatheter aortic valve implantation (TAVI). METHODS Two hundred and eight consecutive patients that underwent transfemoral TAVI at two hospitals (Imperial, College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom and San Raffaele Scientific Institute, Milan, Italy) were included. Daily venous plasma CRP levels were measured for up to 7 d following the procedure (or up to discharge). Procedural factors and 30-d safety outcomes according to the Valve Academic Research Consortium 2 definition were collected. RESULTS Following TAVI, CRP significantly increased reaching a peak on day 3 of 87.6 ± 5.5 mg/dL, P < 0.001. Patients who developed clinical signs and symptoms of sepsis had significantly increased levels of CRP (P < 0.001). The presence of diabetes mellitus was associated with a significantly higher peak CRP level at day 3 (78.4 ± 3.2 vs 92.2 ± 4.4, P < 0.001). There was no difference in peak CRP release following balloon-expandable or self-expandable TAVI implantation (94.8 ± 9.1 vs 81.9 ± 6.9, P = 0.34) or if post-dilatation was required (86.9 ± 6.3 vs 96.6 ± 5.3, P = 0.42), however, when pre-TAVI balloon aortic valvuloplasty was performed this resulted in a significant increase in the peak CRP (110.1 ± 8.9 vs 51.6 ± 3.7, P < 0.001). The development of a major vascular complication did result in a significantly increased maximal CRP release (153.7 ± 11.9 vs 83.3 ± 7.4, P = 0.02) and there was a trend toward a higher peak CRP following major/life-threatening bleeding (113.2 ± 9.3 vs 82.7 ± 7.5, P = 0.12) although this did not reach statistical significance. CRP was not found to be a predictor of 30-d mortality on univariate analysis. CONCLUSION Careful attention should be paid to baseline clinical characteristics and procedural factors when interpreting CRP following TAVI to determine their future management.

State-of-the-art periprocedural 3D transoesophageal echocardiography during transcatheter mitral valve-in-valve implantation

Fax +1 203 785 3346 E-Mail: jshd@scienceinternational.org http://structuralheartdisease.org/ * Corresponding Author: Jason N. Dungu, PhD, BSc, MBBS, MRCP Imperial College Healthcare NHS Trust Hammersmith Hospital Du Cane Rd, White City, London W12 0HS, UK Tel.: +44 20 8383 1000, Fax: +44 20 3313 4232, E-Mail: j.dungu@nhs.net

109 LEFT VENTRICULAR REMODELLING IN BARIATRIC PATIENTS: STUDY WITH 4D ECHOCARDIOGRAPHY AND STRAIN

Purpose The aim of this study was to examine left ventricular (LV) echocardiographic indices, 4D volumes and ejection fraction of bariatric patients (BMI >40). Methods Forty-nine consecutive normotensive bariatric patients (31 women (63.2%), 43 Caucasian, mean age: 45.7±9.7 years, BMI ≥40 kg/m2) were examined with 3D and speckle tracking echocardiography pre-bariatric surgery and they were compared with an age-matched group of 30 healthy volunteers. Exclusion criteria were coronary artery disease, cardiomyopathies and arrhythmias. Statistical analysis was performed with SPSS V.14.0 and Medcalc softwares. All indices were indexed to body surface area and heart rate, where appropriate. Results Common comorbidities comprised diabetes mellitus (N=7), fatty liver (N=8), hypertension (N=8) and sleep apnoea (N=12). 2D echocardiography demonstrated dilatation of the left atrium in bariatric patients when compared to healthy volunteers (39.2±1.9 vs 32.3±2.6 mm, p<0.01); LV end-diastolic diameter was increased (49.2±4.8 vs 42.9±3 mm). 4D values demonstrated an increase in LV end-diastolic volume (182.5±47.7 vs 116.1±15.9 ml); LV ejection fraction was preserved, however lower when compared to healthy volunteers (57.8±7.4 vs 68.4±5.9%). LV mass was also greater in bariatric patients (107.5±28 vs 84.7±11.6 grs). When performing strain with Echopac, there was a contraction delay of global strain in bariatric patients when compared to healthy volunteers (p<0.05). Conclusions Bariatric patients demonstrate increase of LV mass, dilatation of the ventricle and signs of diastolic heart failure with preserved ejection fraction.