Rajamiyer Venkateswaran

N-terminal pro-brain-type natriuretic peptide: a biochemical surrogate of cardiac function in the potential heart donor,

OBJECTIVESnN-terminal pro-B-type natriuretic peptide (NT-proBNP) is elevated in subarachnoid haemorrhage, brainstem death (BSD) and heart failure. We examined the relationship between NT-proBNP and cardiac functional status after BSD and left ventricular (LV) BNP precursor gene expression.nnnMETHODSnWe assayed NT-proBNP in the serum of potential heart donors investigated with pulmonary artery flotation catheters, transthoracic echocardiography and cardiac troponin (cTn) I and T. After 6.9 h of optimisation, haemodynamic studies were repeated to determine haemodynamic functional suitability for transplantation. Median (interquartile range (IQR)) NT-proBNP levels are reported according to initially measured dichotomised pulmonary capillary wedge pressure (PCWP), cardiac index (CI), indexed cardiac power output (CPOi), left ventricular ejection fraction (LVEF), wall motion score (WMS), extravascular lung water index (EVLWI), cTnT and cTnI and end-management functional suitability. LV biopsies were snap-frozen, mRNA extracted and reverse-transcribed, allowing performance of Taqman real-time polymerase chain reaction assays of mRNA-BNP precursor.nnnRESULTSnThere were 79 subjects. Median NT-proBNP was 121 pg ml(-1) (range 5-4139) and levels correlated with time from coning (p<0.01, r=-0.379). Higher NT-proBNP was found in donors with PCWP >14 mmHg; 504 (120-1544) versus 101 (38-285); p=0.01; CI <2.4 l min(-1) m(-2) 410 (123-1511) versus 95 (37-264); p=0.001; CPOi <0.5 Wm(-2) 256 (78-694) versus 105 (37-315); p=0.02; LVEF <50% 231 (75-499) versus 72 (36-177); p=0.04; WMS >2; 343 (80-673) versus 99 (37-236); p=0.01; cTnT >0.1 microg ml(-1) 499 (127-967) versus 80 (36-173); p<0.001 and cTnI >1 mg ml(-1) 410 (97-684) versus 88 (36-190); p<0.01 and in hearts functionally unsuitable at end-optimisation; 189 (74-522) versus 85 (39-243); p=0.02. Hearts functionally suitable for transplantation expressed significantly less mRNA encoding for BNP precursor (0.19-fold; p=0.01).nnnCONCLUSIONnDuring or after BSD, NT-proBNP is released and the heart is a likely source. Higher NT-proBNP levels are associated with donor heart dysfunction and a failure to achieve haemodynamic functional suitability criteria. This supports the hypothesis that biomarkers, including NT-proBNP, may be useful in donor heart assessment.

Myocardial recovery with mechanical circulatory support

Mechanical circulatory support (MCS) is instituted in patients with advanced heart failure, some of who may experience sufficient recovery in cardiac function to allow withdrawal of mechanical support. The incidence of left ventricular recovery with MCS is unclear as reported series in the literature demonstrate widely divergent rates. A number of clinical parameters (including echocardiographic, haemodynamic and physiological) are used to indicate likely left ventricular recovery during pump speed reduction but no internationally agreed definition exists. Withdrawal of MCS is not without risk and so robust clinical and biochemical definitions are important to minimize patient morbidity and mortality. Here we review our current understanding of left ventricular recovery with MCS.

Prolonged asystole in a patient with an isolated left ventricular assist device

Left ventricular assist devices (LVADs) are well established in the management of end-stage heart failure as either destination therapy, a bridge prior to cardiac transplantation or during myocardial recovery. Despite LVADs requiring adequate left ventricular preload to effectively augment systemic circulation, there have been rare cases of patients with LVADs surviving sustained, normally fatal arrhythmias, such as ventricular fibrillation and asystole. Whilst current reports describe an LVAD patient surviving 15 days with such an arrhythmia, we describe the case of a patient with an LVAD surviving 104 days of asystole via a Fontan mechanism of circulation, which we believe is the longest known survival of a sustained fatal arrhythmia. This case highlights the physiology of circulations supported by LVADs and the unique challenges that may arise in managing ambulant LVAD patients, such as predicting prognosis. Given the increasing use of LVADs to treat end-stage heart failure, these issues are likely to become more frequently encountered in the future.

Mediterranean and Low-Fat Diets Reduce Cardiovascular Disease after both Heart and Lung Transplantation: Results from a Randomised Trial with 12 Month Follow Up

Background Cardiovascular disease (CVD) reduces survival following cardiothoracic transplantation. In a randomised trial we compared feasibility and effectiveness of Mediterranean and low-fat dietary interventions in decreasing CVD severity. Methods Adult cardiothoracic transplant recipients were randomly allocated to a Mediterranean or low-fat diet for 12 months. Feasibility was measured by participation and retention rates, adherence and acceptability of each diet to patients and families. Weight, blood pressure (BP), blood glucose and lipids, and prednisolone dose were assessed at baseline, intervention mid-point and cessation. Similar outcomes were collected retrospectively from eligible patients who declined participation (surrogate controls). Results Of those approached, 21 of 56 heart transplant recipients and 20 of 60 lung recipients were recruited (45%) and randomised to Mediterranean (n=21) or low-fat (n=20) diets. All but one from each group completed the study (95%). In both groups dietary adherence was high and family members approved. No adverse events related to the intervention were reported. Respective clinical changes in the Mediterranean and low-fat diet groups were: weight (kg), –1.8, –0.2; BMI (kg/m2), –0.5, 0.0; systolic/diastolic BP (mmHg), 0.5/0.1, –4.4/–3.5, and corresponding cardiometabolic changes were: fasting glucose (mmol/L) –0.26, –0.27; total cholesterol (mmol/L) –0.56, –0.40; triglycerides (mmol/L) –0.17, –0.44. Prednisolone doses were reduced in both groups in the 12-month study period. In contrast all routinely recorded CVD risk factors increased among surrogate controls. Conclusions High retention, adherence and family satisfaction indicated that both dietary interventions are feasible. Improved CVD outcomes suggest both are highly beneficial compared with no intervention.

Rheumatoid nodule on the anterior mitral valve leaflet

Symptomatic cardiac rheumatoid nodules are a rare but recognized manifestation of rheumatoid arthritis. We describe the surgical management of a rheumatic nodule involving the anterior leaflet of the mitral valve.

Clinical characteristics and survival in cardiogenic shock admissions to a UK heart transplant unit

AIMnWe describe the characteristics and outcomes of cardiogenic shock (CS) admissions to a UK transplant unit, which is previously unreported.nnnPATIENTS & METHODSnFifty-nine unselected, consecutive patients over a 38-month period in CS (INTERMACS ≤2) and potentially eligible for transplant were retrospectively reviewed.nnnRESULTSnPatients were predominantly male (76.3%), young (mean age 42.2 years) and with severe end-organ dysfunction (acute liver/kidney injury 83%, mean lactate 3.5xa0mmol/l). 57.6% required mechanical support and 28.8% cardiac transplant. 30 days, discharge and 1-year survival were 78, 68 and 63%, respectively. Predictors of death included no transplant, increasing age and increasing creatinine.nnnCONCLUSIONnPatients with CS and potential for transplant require significant resource input but demonstrate favorable outcomes in our experience.

The interval between brainstem death and cardiac assessment influences the retrieval of hearts for transplantation

OBJECTIVESnThe optimum time after brainstem death (BSD) at which to assess the function of donor hearts is unknown. We hypothesized that a longer interval may be associated with a higher transplantation rate due to improved function.nnnMETHODSnData were obtained from the UK Transplant Registry for the period between April 2010 and March 2015. The time when fixed dilated pupils were first noted in the donor was considered as the time of BSD. Retrieval was defined as the time when the abdominal organs were surgically perfused.nnnRESULTSnBSD to retrieval duration was available for 1947 donors, of which 458 (24%) donated their heart. In the univariable analysis (not adjusting other donor risk factors), evidence was available to suggest that the BSD to cardiac assessment duration had a non-linear association with heart utilization (Pu2009<u20090.0001). Adjusting for donor risk factors, the relationship remained with longer intervals being associated with increased transplantation (Pu2009=u20090.0056). The modelled probability of heart utilization had a similar pattern to the observed rate of heart utilization. However, the probability of heart donation began to plateau after approximately 48u2009h. The analysis of the subset of donors attended by a cardiothoracic retrieval team showed a similar pattern.nnnCONCLUSIONSnThese data suggest that time interval from BSD to organ retrieval influences the heart retrieval rate. When the sole reason for declining a donor heart is poor function, a period of further observation and optimization up to 2u2009days should be considered.

Durable left ventricular assist device as a bridge to recovery for addisonian crisis related cardiomyopathy

A 19‐year‐old female with addisonian crisis‐related cardiomyopathy underwent temporary mechanical circulatory support followed by insertion of a durable left ventricular assist device. Successful device explanation was possible 2.5 years following implantation.

Left ventricular assist devices: an evolving journey

Heart failure (HF) consists a global and continuously growing health problem characterized by excessive morbidity and mortality with furthermore significant financial implications regarding treatment costs. Even though orthotopic heart transplantation has proven to be the preferred method of choice for advanced heart failure patients, organ donations are failing to meet clinical needs. This disparity between organ supply and demand has in part promoted the witnessed expansion in the field of mechanical circulatory support devices. At present continuous-flow left ventricular assist devices (LVAD) are the option of choice for advanced heart failure patients requiring long-term mechanical circulatory support.